Adult Emergency Department Research Articles

Outcomes of Vaso-Occlusive Episode Management in Adults Vs. Pediatrics in the Emergency Department

Introduction: Vaso-occlusive episodes (VOEs) contribute to significant morbidity and mortality in patients with sickle cell disease (SCD) and require timely treatment. Prompt intravenous fluids (IVF) and analgesics are key mainstays of care that may influence outcomes such as the increased disease burden from VOE-associated tissue infarction and the development of chronic pain. VOEs often lead to uncontrolled pain, requiring frequent ED (emergency department) visits and hospitalizations. Timely acute care management is crucial for curbing the significant polymerization of hemoglobin (Hgb) S and dehydration, which increases sickling of Hgb and can precipitate VOEs. In this study, we investigate the relationship between variables such as time to first IVF and IV pain medications in the ED for adult and pediatric patients with SCD presenting with VOEs and rates of admission. Methods: A retrospective study was conducted to analyze outcomes of adult and pediatric patients with SCD at Loma Linda University Medical Center ED and Children's Hospital ED. Patients with HgbSS, HgbSC, and HgbS/beta-thalassemia genotypes with at least two encounters at our institution for VOEs were included. Endpoints collected were time to first IVF in the ED, time to first IV pain medication, and rate of admission. Two-sample Wilcoxon rank-sum (Mann-Whitney) test was utilized to compare time to first IVF or pain medication in adult vs pediatric patients and the rates of admission. In these models, age, gender, and genotype were adjusted for. Results: 110 patients, 56 adult and 54 pediatric, with a total of 298 patient encounters were analyzed. In the adult population, 55% were male and 45% were female, with a median age of 30. In the pediatric population, 56% were male and 44% were female, with a median age of 10. Of the patients, 47 adult and 43 pediatric patients had severe genotypes (HgbSS or HgbS/beta-thalassemia). Compared to the adult population, the pediatric group had lower odds of receiving IVF and IV pain medications in < 90 minutes (min) of presentation to the ED (odds ratio (OR): 0.13, p=0.01 & OR: 0.114, p=0.02, respectively), controlling for age, gender, and genotype. There was no significant difference in the median time to first IVF or IV pain medication in adults compared to pediatric patients (p=0.22 and p=0.42, respectively) (Table 1). When comparing adult and pediatric patients who received IVF and IV pain medications in < 90 min vs ≥ 90 min, the rates of admission were lower in the < 90 min groups (rates of admission by time to IVF: 56.9% for ≥ 90 min vs 51.8% for < 90 min in adults & 62.4% for ≥ 90 min vs. 50.1% for < 90 min in pediatric patients; rates of admission by time to IV pain medications: 60.9% for ≥ 90 min vs 12.5% for < 90 min in adults & 60.8% for ≥ 90 min vs 50.5% for < 90 min in pediatric patients) (Table 2). Conclusion: Overall, shorter time to IVF and IV pain medications in the ED led to decreased rates of admission for both adult and pediatric patients, regardless of age, gender, or genotype. Despite higher odds of adults receiving IVF and IV pain medications in < 90 min compared to pediatric patients, there was no difference in median time to IVF or IV pain medications. Thus, developing protocols to decrease the time to IVF and pain medications in the adult and pediatric ED setting may subsequently lead to improved outcomes for patients with SCD. The study calls for larger studies to further elucidate the significance of time to initial IVF and IV pain medications in the acute management of VOEs.

2818. Investigating Urinalysis Criteria that Predict UTI: Impact of age, sex, and urine culture thresholds

Abstract Background Urinalysis (UA) results are used by clinicians and laboratories to aid in the diagnosis of UTI. However, optimal UA parameters have not been systematically investigated or validated for different populations. Our objectives were to assess the performance of UA in predicting UTI and to stratify UA performance by age, sex, and culture thresholds. Methods We conducted a retrospective cohort study of adult non-catheterized inpatient and ED encounters with paired UA and urine cultures (24 hours apart) from 5 community and academic hospitals in three states (NC, VA, GA) between 01/01/2017 and 12/31/2019. Trained abstractors collected clinical and demographic data for a random sample of patients. Patients were classified as having UTI, asymptomatic bacteriuria or ‘not UTI’ based on IDSA guidelines using signs/symptoms and microbiology data. We evaluated the performance of relevant UA parameters in predicting UTI by assessing sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also combined 18 different UA criteria (Figure 1) and used area under receiver operating curves (AUROC) to identify the 5 best-performing models, and stratified results by age, sex, and lower urine culture bacterial threshold (1000 colony forming units). Results Of 219,338 encounters, 3392 charts were included and reviewed; 723 (21.3%) patients met criteria for UTI. Females and older adults had a higher incidence of UTIs and ASB (P< 0.05; Table 1). Absence of pyuria (or leukocyte esterase) had a high NPV for UTI (Table 2). Combined UA parameters performed better than pyuria alone with regards to NPV and AUROC, specifically models 1 and 5 (Table 3). UA parameters used in these models performed differently based on age, sex and urine culture thresholds, with limited utility in older women and UTIs with lower bacterial threshold (Table 4). Conclusion Our review of laboratory and symptom data from a diverse population dataset revealed that combined UA parameters were better at predicting UTI, but performance of UA parameters differs based on age, sex, and urine culture thresholds. Our approach highlights the need to move away from a one-size fits all approach to using population specific UA cut-offs for patients with UTI symptoms. Disclosures Sonali Advani, MBBS, MPH, FIDSA, bioMérieux: Advisor/Consultant|GlaxoSmithKline: Advisor/Consultant Nicholas A. Turner, MD, MHSc, PDI: Research contract to assess efficacy of cleaning agent

879. Host Response Classifiers Identify Infection and Illness Severity and Improve Antibiotic Decision-Making in Patients with Suspected Infections Presenting to the Emergency Department

Abstract Background Nonspecific presentation and limited diagnostic solutions of acute infections and sepsis in emergency departments (EDs) result in early antimicrobial administration at a cost to antimicrobial stewardship. We validated the host response classifiers, IMX-BVN-3b and SEV-3b, to determine bacterial and viral infection status and illness severity. We also assessed antibiotic over- and underuse. Methods We prospectively enrolled adult ED patients with suspected acute infections or sepsis with ≥1 vital sign abnormal across 7 sites. At enrollment, we surveyed treating physicians on infection probability and antibiotic prescribing. BVN/SEV-3b were calculated using NanoString nCounter® on PAXgene® blood samples. We compared BVN-3b likelihood of bacterial and viral infection to post-hoc clinical adjudication infection status and SEV-3b likelihood of severe outcomes to 7-day need for ICU care and 30-day mortality. Results Of 568 enrolled patients, 346 had consensus adjudications (131 bacterial, 52 viral, 1 coinfection, 162 noninfected). The BVN-3b area under the receiver operating curve (AUROC) for bacterial infections was 0.82 (95%CI 0.77-0.87), compared to 0.76 (95%CI 0.71-0.81) for procalcitonin (p = 0.011). BVN-3b AUROC for viral infections was 0.89 (95%CI 0.84-0.95). SEV-3b AUROC was 0.78 (95%CI 0.69-0.86) and 0.88 (95%CI 0.73-1) for 7-day ICU care and 30-day mortality, respectively. Of the 346, 226 patients had a pre-lab result physician questionnaire; of these, 110 patients received antibiotics. Of these, BVN-3b would have corrected 71% of antibiotic prescribing errors (34/48 overprescriptions and 13/18 underprescriptions). Conclusion BVN-3b and SEV-3b accurately identified bacterial and viral infections and risk status. If implemented in a rapid workflow, these tests may improve patient management and antibiotic prescribing, reducing healthcare costs in the ED. Disclosures Arianna Beltran, BS, Inflammatix: Internship Uan-I Chen, MS, Inflammatix: Stocks/Bonds Edward A. Michelson, MD, Inflamatix: Research expense reimbursement for sponsored clinical trial Alexandra Weissman, MD, Inflammatix Inc: Advisor/Consultant Evangelos J. Giamarellos-Bourboulis, PhD, D(ABMM), Abbot Product Operations AG: Grant/Research Support|Abbot Product Operations AG: Honoraria|bioMerieux: Grant/Research Support|bioMerieux: Honoraria|Horizon 2020 European Program: Grant/Research Support|Horizon Health European Program: Grant/Research Support|Sobi AB: Advisor/Consultant|Sobi AB: Grant/Research Support|Sobi AB: Honoraria Oliver Liesenfeld, MD, Inflammatix Inc.: Ownership Interest Natalie N. Whitfield, PhD, D(ABMM), GenMark Dx/Roche: Employee|GenMark Dx/Roche: Stocks/Bonds|Inflammatix: Employee|Inflammatix: Stocks/Bonds

451. Pre- and Post-implementation Comparison of the Impact of Emergency Department (ED)-Based COVID-19 Point-of-Care Testing on ED Patient Metrics

Abstract Background Use of Point of Care Testing (POCT) in Emergency Departments (EDs) may afford the opportunity to improve key ED operational metrics. We evaluated the impact of COVID-19 POCT on time to delivery of test results, rates of patients who left the ED with or without a COVID-19 diagnosis, and the amount of time COVID-19-negative patients spent in isolation. Methods Retrospective pre-POCT (7/1/2020 – 8/31/2020, N=4105) and post-POCT (1/1/2021 – 3/31/2021, N=4795) implementation analysis of patients presenting to the Johns Hopkins Hospital Adult ED who received symptomatic COVID-19 testing. Both pre- and post-implementation POCT was performed using the Cepheid GeneXpert SARS-CoV-2 or SARS-CoV-2/Flu A/B/RSV nucleic acid tests, which have a run time of 45 minutes; pre-POCT occurred in the hospital central lab and POCT occurred in a POC testing lab established in the ED. Results Post-implementation, the time from arrival to test result for all patients decreased by an average of 133.2 ± 3.3 minutes; the time to delivery of test result decreased by 177.4 ± 16.02 minutes for COVID+ patients. Reduction in time to test result was associated with a significant decrease in the percentage of patients who were discharged from the ED without their result being known prior to departure: pre-implementation, 8.7% of all tested patients left without a known result, with 21% of COVID+ patients leaving prior to receiving a diagnosis; post-implementation, only 0.92% of all tested patients and 0.68% of COVID+ patients left the ED without a final COVID diagnosis. The amount of time COVID-19 negative patients spent in isolation in the ED decreased by an average of 129.7 ± 3.3 minutes post-POCT implementation. Conclusion Use of ED POCT for COVID-19 in the ED resulted in more rapid time to test results and fewer patients leaving the ED who did not know their COVID-19 status, decreasing the likelihood that a COVID+ patient would unknowingly expose others in the community. Additionally, the improved time-to-test-result reduced the amount of time COVID-negative patients spent in isolation, enabling clinical staff to avoid unnecessary PPE usage and free up negative pressure beds. Disclosures Katherine ZJ Fenstermacher, PhD, Cepheid: Grant/Research Support Jeanne Mumford, MT, Cepheid Speaker Bureau: Advisor/Consultant|Cepheid Speaker Bureau: Honoraria Richard E. Rothman, MD, PhD, CEPHEID: Advisor/Consultant|Cepheid: Grant/Research Support|Danaher: Grant/Research Support

Introduction of a high sensitivity troponin reduces ED length of stay

BackgroundHigh sensitivity cardiac troponins (hs-cTn) allow earlier identification and exclusion of acute myocardial infarction. We determined if transitioning from contemporary to high sensitivity troponin T (hs-cTnT) would reduce ED length of stay in chest pain (CP) patients. MethodsWe conducted a pragmatic, prospective, before and after study of implementing a hs-cTnT by reviewing the electronic health records in all adult ED patients presenting to a large, suburban academic medical center during the 3 months before and after transitioning from a 4th generation troponin to a 5th generation hs-cTnT (Elecsys® Troponin T-high sensitive, Roche Diagnostics, Indianapolis, IN). ResultsThere were 1431 and 1437 CP patients before and after the intervention. Mean (SD) age was 51.5 (18) yrs. and 54.3% were female. The median (IQR) ED LOS for chest pain patients directly discharged to home was 6.2 (4.7–8.4) and 5.3 (4.0–7.2) hours before and after introducing hs-cTn respectively; difference 47 min (95%CI, 35–59); P < 0.001. The median (IQR) ED LOS for chest pain patients admitted to the hospital was 9.5 (6.6–13.8) and 8.1 (5.7–11.2) hours before and after introducing hs-cTn respectively; difference 77 min (95%CI, 35–121); P < 0.001. Overall admission rates (22 vs 21% both before and after) did not change during the study. The rates of computed tomography coronary angiography before and after the intervention were 21 and 20.4% respectively. The rates of invasive coronary angiography before and after the intervention were 5.8 and 5.6% respectively. ConclusionsTransitioning to a hs-cTnT is associated with a clinically relevant and statistically significant reduction in ED LOS for both discharged and admitted patients with and without CP with no increase in admission or coronary angiography rates.

Emergency Department Buprenorphine Quality Improvement and Emergency Physician Knowledge, Attitudes, and Self-Efficacy.

Buprenorphine is an evidence-based treatment for opioid use disorder that is underused in the emergency department (ED). In this study we evaluated changes in emergency physician knowledge, confidence, and self-efficacy regarding buprenorphine prescribing and working with patients who use drugs after implementation of an ED buprenorphine quality improvement (QI) initiative. An anonymous, online survey was administered to emergency physicians staffing four EDs in New England in 2019 and 2020 before and after an ED QI initiative. Survey questions included novel and previously validated questions to assess confidence, knowledge, self-efficacy, and attitudes about buprenorphine and working with patients who use drugs. Confidence, self-efficacy, and attitude responses were assessed on a Likert scale. Participants received a gift card for survey completion. We analyzed pre- and post- survey responses descriptively and compared them using t-tests. Using logistic regression we evaluated the factors associated with buprenorphine prescribing. Of 95 emergency physicians, 56 (58.9% response rate) completed the pre-intervention survey and 60 (63.2%) completed the post-survey. There was an increase in the number of X-waivered adult emergency physicians and ED buprenorphine prescribing after program implementation. Physician confidence increased from a mean of 3.4 (SD 0.8) to 3.9 (SD 0.7; scale 1-5, p < 0.01). Knowledge about buprenorphine increased from a mean score of 1.4 (SD 0.7) to 1.7 (SD 0.5, p < 0.01). Physician attitudes and self-efficacy did not change. Post-initiative, increased confidence was associated with higher odds of buprenorphine prescribing (odds ratio 4.4; 95% confidence interval 1.07-18.4). After an ED QI initiative, buprenorphine prescribing in the ED increased, as did both physician confidence in working with patients who use drugs and their knowledge of buprenorphine. Increased confidence was associated with higher odds of buprenorphine prescribing and should be a focus of future, buprenorphine implementation strategies in the ED.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis.

Euglycemic diabetic ketoacidosis (DKA) (glucose <250milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561mg/dL, P < 0.001) and potassium (4.3 vs 5.3mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3mmol/L) was 27.3 vs 19.1% (P = 0.23). Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

Patient sex, racial and ethnic disparities in emergency department triage: A multi-site retrospective study

ObjectivesThere is limited evidence on sex, racial, and ethnic disparities in Emergency Department (ED) triage across diverse settings. We evaluated differences in the assignment of Emergency Severity Index (ESI) by patient sex and race/ethnicity, accounting for age, clinical factors, and ED operating conditions. MethodsWe conducted a multi-site retrospective study of adult patients presenting to high-volume EDs from January 2019–February 2020. Patient-level data were obtained and analyzed from three EDs (academic, metropolitan community, and rural community) affiliated with a large health system in the Southeastern United States. For the study outcome, ESI levels were grouped into three categories: 1–2 (highest acuity), 3, and 4–5 (lowest acuity). Multinomial logistic regression was used to compare ESI categories by patient race/ethnicity and sex jointly (referent = White males), adjusted for patient age, insurance status, ED arrival mode, chief complaint category, comorbidity score, time of day, day of week, and average ED wait time. ResultsWe identified 186,840 eligible ED visits with 56,417 from the academic ED, 69,698 from the metropolitan community ED, and 60,725 from the rural community ED. Patient cohorts between EDs varied by patient age, race/ethnicity, and insurance status. The majority of patients were assigned ESI 3 in the academic and metropolitan community EDs (61% and 62%, respectively) whereas 47% were assigned ESI 3 in the rural community ED. In adjusted analyses, White females were less likely to be assigned ESI 1–2 compared to White males although both groups were roughly comparable in the assignment of ESI 4–5. Non-White and Hispanic females were generally least likely to be assigned ESI 1–2 in all EDs. Interactions between ED wait time and race/ethnicity-sex were not statistically significant. ConclusionsThis retrospective study of adult ED patients revealed sex and race/ethnicity-based differences in ESI assignment, after accounting for age, clinical factors, and ED operating conditions. These disparities persisted across three different large EDs, highlighting the need for ongoing research to address inequities in ED triage decision-making and associated patient-centered outcomes.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis.

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions. The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity. Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity). Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity. This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Growth differentiation factor-15 is associated with myocardial infarction and death at 30 and 90 days in ED patients with suspected acute coronary syndrome

Abstract Background Growth differentiation factor (GDF)-15 is a novel biomarker of cardiac stress that may be an accurate predictor of mortality and acute myocardial infarction (AMI) in patients with acute chest pain. However, data from US populations are lacking. Purpose Our objective was to determine whether GDF-15 is an independent predictor of index, 30-day, and 90-day day AMI and death in a U.S cohort of ED patients with possible acute coronary syndrome. Methods This study was a secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) trial, which prospectively enrolled adults (≥ 21 years) presenting to eight emergency departments in the US with suspected AMI (1/25/2017-9/6/2018). Blood sampling was performed at baseline and 3 hours later, and hs-TnT, NT-pro-BNP, and GDF-15 assays were performed at a central laboratory. The primary outcome was the composite of AMI and all-cause death at index visit, 30 days, and 90 days and secondary outcomes were AMI and death separately. Multivariable logistic regression models were fitted for the outcomes at each timepoint with the following independent variables: age, sex, number of cardiac risk factors, ECG findings, hs-TnT, and NT-pro-BNP. Odds ratios (ORs) are reported per 100 ng/L increase in GDF-15 levels. Results In 1,428 patients the median age was 58 (IQR: 49, 66) years and 25% (353/1,428) had a history of coronary artery disease. The median GDF-15 level was 1,233 pg/mL (IQR: 754, 2206) at baseline and 1,363 pg/mL (IQR: 851, 2434) at 3 hours. The composite outcome of AMI or death occurred in 12% (169) at index visit, an additional 2% (34) at 30 days, and an additional 3% (37) at 90 days. In multivariable regression models, GDF-15 was independently associated with the composite outcome of AMI or death at 30 days (OR ng/L 1.01, 95% CI 1.00-1.02) and 90 days (OR 1.01, 95% CI 1.01-1.02), but not during the index visit (OR 1.00, 95% CI 1.00-1.00). It was also associated with both AMI (OR 1.01, 95% CI 1.00-1.02) and death (OR 1.01, 95% CI 1.01-1.02) separately at 90 days, but was only associated with death (OR 1.01, 95% CI 1.01-1.02) at 30 days. Conclusion Among adult ED patients with suspected AMI, GDF-15 was independently associated with subsequent 30-day and 90-day AMI or death. These data suggest a potential role for GDF-15 in risk stratifying ED patients with regard to future cardiac events.

Adult Mental Health Presentations to Emergency Departments in Victoria, Australia between January 2018 and October 2020: Changes Associated with COVID-19 Pandemic Public Health Restrictions

The COVID-19 pandemic and associated public health measures altered patterns of help-seeking for mental health, with increases in emergency department utilisation reported. We examined the association between COVID-19 restrictions and adult emergency department (ED) mental health presentations in Victoria, Australia, through secondary analysis of data from 39 public EDs across the state. Participants were all patients (18+ years) presenting between 1 January 2018 and 31 October 2020 with mental health or intentional self-harm. The main outcome was number of presentations for each mental health condition, by patient age, socioeconomic status (SES), location, and ED triage category. We used a Poisson regression model to compare predicted monthly ED presentations based on trends from 2018, 2019 and 2020 (up to 31 March), with observed presentations during the initial months of the COVID-19 pandemic (1 April to 31 October 2020). There was an average of 4,967 adult mental health presentations per month pre-COVID-19 (1 January–31 March 2020) and 5,054 per month during the COVID-19 period (1 April–31 October 2020). Compared to predicted incidence, eating disorder presentations increased 24.0% in the COVID-19 period, primarily among higher SES females aged 18–24 years. Developmental/behavioural disorder presentations decreased by 19.7% for all age groups. Pandemic restrictions were associated with overall increases in monthly adult ED presentations for mental health, with some disorders increasing and others decreasing. Accessibility of acute mental health services needs to be addressed to meet changing demand and ensure services are responsive to changes in presentations resulting from future public health challenges.

Abstract 247: Assessing Feasibility of Proposed Extracorporeal Cardiopulmonary Resuscitation Programs in Scotland via Geospatial Modelling

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) may improve outcomes for out-of-hospital cardiac arrest (OHCA) where return of spontaneous circulation (ROSC) is not achieved. We estimated the number of patients who may benefit from proposed in-hospital or pre-hospital ECPR programs in Scotland. Methods: EMS-treated atraumatic OHCAs occurring in Scotland between Apr. 2017-Mar. 2022 were included. We identified those likely to benefit (age 16-70, initial rhythm VF/pVT, no ROSC) and those possibly likely to benefit (age 16-70, initial rhythm PEA, no ROSC) from ECPR. To achieve timely ECPR initiation within 60 mins, we computed the number of eligible OHCAs within 15 mins’ drive time surrounding each of the 3 ECPR-capable hospitals, 6 percutaneous coronary intervention (PCI)-capable hospitals, and 28 adult emergency departments (ED) for in-hospital ECPR programs. We then computed the number of eligible OHCAs within a 45-minute drive time surrounding each of the 28 EDs and 140 ambulance stations and determined locations allowing one dedicated pre-hospital ECPR service to reach the greatest number of eligible OHCAs. We accounted for service availability based on 8 and 16-hour availability on weekdays and 24/7 availability. Results: Of the 8,962 OHCAs included, 1,108 (12.3%) were classified likely to benefit, 4,675 (52.2%) possibly likely to benefit, and 3,179 (35.5%) unlikely to benefit from ECPR. In-hospital ECPR scenarios covered up to 12.5% of eligible OHCAs at ECPR-capable hospitals, 20.9% at PCI-capable hospitals, and 64.6% at all EDs. Pre-hospital ECPR scenarios with one crew covered up to 51.0% and 54.1% when based at an ED or ambulance station respectively, which were higher than respective in-hospital scenarios at ECPR-capable or PCI-capable hospitals, and were generally comparable to ECPR availability at all 28 EDs. Conclusion: A pre-hospital ECPR service can generally reach greater numbers of OHCAs compared to in-hospital ECPR programs.

Abstract 14946: Sex Differences in Growth Differentiation Factor-15 and Association With Acute Myocardial Infarction and Death at 90 Days in Emergency Department Patients Presenting With Acute Chest Pain and Normal Troponin Levels

Introduction: Growth differentiation factor (GDF)-15, a novel biomarker of cardiac stress, has been recently studied as a tool in predicting cardiovascular outcomes in patients with acute chest pain, when compared against high-sensitivity troponin T (hs-TnT). However, GDF-15 is not approved for cardiac indications in the United States, with limited nationwide data evaluating subpopulations by key demographic and clinical characteristics. Hypothesis: GDF-15 levels demonstrate sex-specific differences and serve as an independent predictor of 90-day acute myocardial infarction (MI) and all-cause death in patients presenting to the emergency department (ED) with acute chest pain and normal hs-TnT levels. Methods: This study was a secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) trial, which prospectively enrolled adults ≥ 21 years presenting to eight EDs in the US with suspected acute MI over a twenty-month period. Blood sampling was performed at presentation, with hs-TnT and GDF-15 assays performed at a central laboratory. The outcomes of interest were the composite of acute MI and all-cause death at 90 days. Multiple logistic regression models were fitted for timepoint with multiple independent variables including the following: age, sex, ischemic electrocardiogram, hs-TnT, GDF-15, and creatinine. Results: We studied 1,428 patients; median age was 58 years and 54% (765) were male. The composite outcome of acute MI or death occurred in 3% (37) at 90 days. In multivariable regression models in patients with baseline normal hs-TnT levels, GDF-15 was associated with acute MI or all-cause death at 90 days (Odds Ratio 1.03, 95% Confidence Interval 1.01-1.05). Median GDF-15 levels were 1266 pg/mL in males (25th percentile-75th percentile, 914-2038 pg/mL), and 1504 pg/mL in females (25th percentile-75th percentile, 987-2197 pg/mL). Conclusions: Among adult ED patients presenting with acute chest pain with normal troponin levels, the novel biomarker GDF-15 was independently associated with 90-day acute MI or death, with higher median GDF-15 levels in females compared to males. These data suggest a role for GDF-15 in short-term cardiac risk stratification.

Transcutaneous electrical nerve stimulation (TENS) versus sham TENS in adult ED patients with abdominal pain: A clinical trial

ObjectiveThere is a growing consensus that the risks of current pharmacologic analgesics warrant consideration of alternative modalities for acute and chronic pain control. The objective of this study was to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) in adult emergency department (ED) patients presenting with abdominal pain. MethodsWe conducted a patient and observer blinded randomized controlled trial comparing TENS to sham TENS. The study was conducted at a large suburban academic ED. Patients with abdominal pain and a verbal numeric pain scale (VNS) of 5 or greater were randomized to TENS or sham TENS applied via 4 skin pads, one in each abdominal quadrant for 30 min. The primary outcome was change in pain scores 30 min after the intervention. Our study had 80% power to detect a between group difference of 1.5 points on the VNS. Results81 patients were randomized to TENS (n = 41) or sham TENS (n = 40). Groups were similar in baseline characteristics. The mean (SD) reductions in pain scores were 1.9 (2.1) and 1.7 (2.6) in patients treated with TENS and sham TENS respectively (P = 0.81). Use of rescue medications in patients with treated with TENS and sham TENS was similar (49 vs 55% respectively, P = 0.66). ConclusionsApplication of TENS to the abdominal wall did not result in more effective pain relief than sham TENS in adult ED patients with abdominal pain.

Every Tube Counts: reducing extra tubes drawn in the emergency department

A common practice exists in hospitals where extra tubes of blood are collected for possible add-on testing, this practice contributes to wastage of consumables. Baseline estimates from a 5-month local...

Role of Venous Blood Gase (VBG) Analysis in Patient Triage in the Adult Emergency Department

Background: In emergency and critical care settings, can a venous blood gas analysis improve clinical decision-making and patient outcomes? Methods: This is a cross-sectional study, conducted between January and June 2022 at a tertiary hospital in Saudi Arabia. Results: A total of 100 patients were included, using a convenience sample technique. Their mean age was 54 years, and theirmain chief complaints were shortness of breath (30%), abdominal pain (15%), and altered level of consciousness (14%). The venous blood gas (VBG) result was abnormal in 86 patients, and predicted the need for early intervention in 69 patients (69.7%). A significant association was found between patients requiring early intervention and those with an abnormal VBG (p=0.0005). Furthermore, the VBG results changed the Canadian Triage and Acuity Scale (CTAS) level in 32 patients (33.68%). A logistic regression analysis revealed that pre-testing factors such as age, gender, comorbidities, and chief complaints were not predictors of VBG results, the need for early intervention, or altered CTAS level. Conclusion: Our study concludes that VBG analysis can play an important role in patient triage in the emergency department (ED), allowing for earlier intervention and potentially improving outcomes.

Effectiveness of a multimodal intervention to improve blood culture collection in an adult emergency department.

We investigated the impact of a multimodal intervention to improve the compliance of BC collections as a composite outcome, taking into account both blood volume collected and absence of solitary BC. We performed a quasi-experimental study using a before-after design (5months for pre- and post-intervention evaluation) in an adult emergency department at a tertiary care hospital that showed that a multimodal intervention was associated with a dramatic increase in the proportion of blood cultures that were collected as recommended per national guidelines, from 17.3% (328/1896) to 68.9% (744/1080), P < 0.0001. The implementation of such intervention in other settings could improve the diagnosis of bloodstream infections and reduce irrelevant costs.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BackgroundThe end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. ObjectiveThis study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. MethodsThe study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. ResultsThe study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1–46.3%; p < 0.001) and 22.1% (95% CI 19.3–26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1–3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. ConclusionsTotal adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Determinants of hypertensive crisis among hypertensive patients at adult emergency departments of public hospitals in Addis Ababa, Ethiopia, 2021: a case–control study

BackgroundHypertension (HTN) is a major global health problem that affects approximately 1.13 billion people worldwide, and 1–2% of this population has hypertensive crisis. Hypertensive crisis is becoming a major health issue in low-income countries. However, few studies have been conducted in developing countries such as Ethiopia. This study aimed to assess the determinants of hypertensive crisis among patients visiting adult emergency departments of public hospitals in Addis Ababa.MethodA hospital-based unmatched case–control study was conducted among 85 cases with a hypertensive crisis and 170 controls with hypertension without a hypertensive crisis in the adult emergency departments of public hospitals in Addis Ababa from March 15 to May 15, 2021. Data were collected using a structured questionnaire and analyzed using SPSS version 26. Binary logistic regression and multivariable logistic regression were performed. Finally, a statistically significant level was declared at a p value of less than 0.05. The result was summarized and presented in text, tables, and graph.ResultThe odds of having hypertensive crisis were 3.6 times (AOR = 3.621) higher among participants with a history of hypertension compared to those without a history of hypertension. There was also 4 times increased risk of hypertensive crisis among participants who presented with diabetes mellitus than participants who presented without it (AOR = 4.179). Similarly, participants who presented with stroke had 7 times higher odds of having hypertensive crisis (AOR = 7.174) than participants without stroke.ConclusionThis study demonstrated a statistically significant association between unemployment, diabetes mellitus, stroke, heart failure, history of hypertension, family history of hypertension, and regular follow-up with a hypertensive crisis. The Ethiopian Ministry of Health, Ababa City Administration Health Bureau, and hospitals shall give due attention to the HTN crisis. Health care workers, hospital managers, and other stakeholders shall work towards the early detection and management of HTN-crisis to prevent related morbidity, disability, and mortality.

397 Analysis of Follow-Up Chest Radiography for Adult Emergency Department Patients

397 Analysis of Follow-Up Chest Radiography for Adult Emergency Department Patients