Emergency Department Assessment Research Articles

Impact of first-line dalbavancin for cellulitis on hospital admissions and costs: a case series

BackgroundMany patients with cellulitis are treated with oral antibiotics as outpatients, but some require hospital admission for intravenous antibiotics. During the coronavirus disease 2019 pandemic, Betsi Cadwaladr University Health Board (BCUHB) in Wales approved use of dalbavancin as first-line intravenous antibiotic from April to December 2020 to facilitate early discharge and prevent hospital admission. ObjectivesTo report cost savings and admission avoidance through first-line intravenous use of dalbavancin for cellulitis in one health board in Wales. Patients and methodsPatients with cellulitis who presented to the emergency department (ED) or medical assessment unit (MAU) at BCUHB's two hospitals between April and December 2020 were identified for treatment with dalbavancin, because they had not responded to oral antibiotics or their initial presentation warranted intravenous antibiotics. Patients received 1500mg dalbavancin by intravenous infusion according to prescribing information and were sent home without being admitted. Outcomes were admission within 30 days of dalbavancin and cost savings from avoiding admission. Results31 patients were treated with dalbavancin for cellulitis in the ED or MAU. No patient was admitted within 30 days of receiving dalbavancin. Use of dalbavancin is estimated to have saved 248 bed-days over the study period, with an estimated saving of $120,444.23 based on avoidance of admission. The cost of dalbavancin for these 31 patients was $69,959.08, giving an overall cost saving of $50,485.15 ($1,529.95 per patient). ConclusionsPrescribing dalbavancin as first-line intravenous antibiotic for cellulitis prevents admission, saving bed-days and admission-related costs.

610 From Flames to Facts: Unveiling Discrepancies in Burn Patient Documentation

Abstract Introduction Comprehensive and accurate burn documentation is essential for initial and ongoing patient care. However, the challenge of inaccurate and incomplete records poses preventable risks. Our study evaluates burn documentation at a tertiary care burn centre, focusing on discrepancies between initial Emergency Department (ED) assessments and final evaluations by the Plastic Surgery Burn Consultant (PS). We hypothesize that the ED reports inaccurate and incomplete burn injury details, leading to differences in burn size and severity compared to PS assessments. Methods We conducted a retrospective review of our provincial burn registry from January 1, 2016, to December 31, 2021. We included patients admitted for burns warranting a PS consultation, excluding isolated first-degree, ocular, and inhalational burns, and those not requiring burn unit admission. Data covering time, date, etiology, injury details, treatment, and follow-up were collected and compared between ED and PS records. Incomplete entries lacked burn-specific data points. Mann-Whitney and Kruskal-Wallis H tests were used to compare continuous outcomes, while Pearson’s Chi-Square test was employed for categorical outcomes. Wilcoxon’s Signed-Rank test was used to identify significant variations in TBSA estimates, with PS considered the "gold" standard. Statistical significance was set at p< 0.05. Results 358 patients were included, with most burns in male patients (76%) occurring at home and involving the head and neck. Burn etiology, circumstances, place, and anatomic location were well reported and consistent across PS and ED documentation. However, there were significant differences in TBSA estimates. The ED calculated a median TBSA of 20 (IQR: 19.8), while PS estimated a median TBSA of 14 (IQR: 16) (p< 0.0019). Notably, TBSA estimates for burns < 10% and 10-25% showed significant differences (p< 0.0001), tending toward overestimation by the ED. Deeper burns were consistently over-reported during initial ED assessments compared to the final PS determinations. Furthermore, 81% of the initial records were incomplete: 66% lacked initial treatment data, 49% missed TBSA, and 39% omitted burn depth. Conclusions Significant discrepancies were appreciated in the initial ED documentation of burn injuries at our tertiary care burn centre, with overestimations in TBSA and burn depth. Over 80% of initial documentation was incomplete, with TBSA omitted in 49% of charts in both local and peripheral transfer consultations. There is a collective urgent need for enhanced awareness and education on the importance of accurate and comprehensive burn patient documentation. Applicability of Research to Practice This research emphasizes the need for improved documentation strategies for burn patients seen in the acute care setting, raising the potential to venture into modalities such as artificial intelligence and electronic health record systems to enhance burn documentation.

Impact of a Nationwide Medication History Sharing Program on the Care Process and End-User Experience in a Tertiary Teaching Hospital: Cohort Study and Cross-Sectional Study.

Timely and comprehensive collection of a patient's medication history in the emergency department (ED) is crucial for optimizing health care delivery. The implementation of a medication history sharing program, titled "Patient's In-home Medications at a Glance," in a tertiary teaching hospital aimed to efficiently collect and display nationwide medication histories for patients' initial hospital visits. As an evaluation was necessary to provide a balanced picture of the program, we aimed to evaluate both care process outcomes and humanistic outcomes encompassing end-user experience of physicians and pharmacists. We conducted a cohort study and a cross-sectional study to evaluate both outcomes. To evaluate the care process, we measured the time from the first ED assessment to urgent percutaneous coronary intervention (PCI) initiation from electronic health records. To assess end-user experience, we developed a 22-item questionnaire using a 5-point Likert scale, including 5 domains: information quality, system quality, service quality, user satisfaction, and intention to reuse. This questionnaire was validated and distributed to physicians and pharmacists. The Mann-Whiteny U test was used to analyze the PCI initiation time, and structural equation modeling was used to assess factors affecting end-user experience. The time from the first ED assessment to urgent PCI initiation at the ED was significantly decreased using the patient medication history program (mean rank 42.14 min vs 28.72 min; Mann-Whitney U=346; P=.03). A total of 112 physicians and pharmacists participated in the survey. Among the 5 domains, "intention to reuse" received the highest score (mean 4.77, SD 0.37), followed by "user satisfaction" (mean 4.56, SD 0.49), while "service quality" received the lowest score (mean 3.87, SD 0.79). "User satisfaction" was significantly associated with "information quality" and "intention to reuse." Timely and complete retrieval using a medication history-sharing program led to an improved care process by expediting critical decision-making in the ED, thereby contributing to value-based health care delivery in a real-world setting. The experiences of end users, including physicians and pharmacists, indicated satisfaction with the program regarding information quality and their intention to reuse.

Applying Sydney Triage to Admission Risk Tool (START) to improve patient flow in emergency departments: a multicentre randomised, implementation study

BackgroundTo determine the effectiveness of applying the Sydney Triage to Admission Risk Tool (START) in conjunction with senior early assessment in different Emergency Departments (EDs).MethodsThis multicentre implementation study, conducted in two metropolitan EDs, used a convenience sample of ED patients. Patients who were admitted, after presenting to both EDs, and were assessed using the existing senior ED clinician assessment, were included in the study. Patients in the intervention group were assessed with the assistance of START, while patients in the control group were assessed without the assistance of START. Outcomes measured were ED length of stay and proportion of patients correctly identified as an in-patient admission by START.ResultsA total of 773 patients were evaluated using the START tool at triage across both sites (Intervention group n = 355 and control group n = 418 patients). The proportion of patients meeting the 4-hour length of stay thresholds was similar between the intervention and control groups (30.1% vs. 28.2%; p = 0.62). The intervention group was associated with a reduced ED length of stay when compared to the control group (351 min, interquartile range (IQR) 221.0–565.0 min versus 383 min, IQR 229.25–580.0 min; p = 0.85). When stratified into admitted and discharged patients, similar results were seen.ConclusionIn this extension of the START model of care implementation study in two metropolitan EDs, START, when used in conjunction with senior early assessment was associated with some reduced ED length of stay.

External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome.

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing.

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting. The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results. The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians). By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities. The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.

Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics

PurposeTo investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures.MethodA prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures.ResultsOut of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors.ConclusionMaxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.

Airway assessment in Emergency Department: Different, Difficult, and Dependent on patients’ cooperation

Airway assessment in Emergency Department: Different, Difficult, and Dependent on patients’ cooperation

Suicide attempt management among Turkish and American adolescents: A comparison of two pediatric emergency departments.

Suicide is one of the leading causes of death among adolescents. This study aimed to compare the characteristics and short-term outcomes of Turkish and American adolescents with suicide attempts and determine the differences in management and resource utilization between two pediatric emergency departments; one in Türkiye and one in the United States of America. Adolescents who presented to the emergency departments with a chief complaint of suicide attempt between October 2017 and September 2018 were eligible for including in the study. Characteristics and other information of 217 (131 American and 86 Turkish) suicide attempter adolescents were retrieved from medical records. Outcome was defined as re-admission to the emergency department for another suicide attempt within 3 months of the index visit. Overall, 78% of adolescents were female. Abuse history (physical/sexual) was more common among American adolescents (p = 0.005), whereas uncontrolled psychiatric diseases were more evident in Turkish cases (p < 0.001). Social worker assessment and hospitalization rates were significantly lower, with shorter mean duration of follow-up in the emergency department among Turkish compared to American adolescents (respectively, p < 0.001, p < 0.001 and p = 0.002). Repeated suicide attempts within three months were significantly higher in the Turkish group compared to the American one (29% vs. 8%, p < 0.001). Receiving a social worker assessment, hospitalization and longer observation in emergency department reduced the incidence of repeated suicide attempts (respectively, p < 0.001, p = 0.003 and p = 0.012). Turkish adolescents had shorter observation time in the emergency department, received fewer assessment by social workers and were less likely to be hospitalized. These may have contributed to the higher rate of repeat suicide attempts following discharge from the emergency department. Adequate resources are needed to help decrease the burden of suicide among Turkish adolescents.

Outpatient Management of Sickle Cell Vaso-Occlusive Crisis As a Strategy of Decreasing Emergency Department Visits

Background: Complications of sickle cell disease (SCD), including vaso-occlusive crises (VOC), usually require emergency room visits or even hospitalization for management. Outpatient treatment programs have been developed for management of VOC, however the literature is limited as to the efficacy of these models. Previously, patients in Edmonton, Canada followed by the Hemoglobinopathy Clinic would have to present to the emergency department (ED) for assessment of and management of VOC. Since 2019, patients experiencing early VOC symptoms were able to present to the Medical Outpatient Unit (MOU), an infusion clinic shared with other benign and malignant hematology conditions, to be assessed and receive treatment. This study retrospectively evaluated the outcomes of this treatment strategy. Hypothesis: Outpatient management of VOC is an effective way to assess patients and provide appropriate treatment, thereby reducing the frequency of ED presentations for SCD patients. Methods: Patients were able to schedule their own appointments and were encouraged to present early before they developed severe symptoms. They would be assessed by a nurse, who could then release orders from their personalized pain plan, which is a standing set of orders from an SCD clinic physician. Examples of orders include intravenous fluids and pain medications. Based on the severity of symptoms, patients could also be referred to the ED or for assessment by a physician or nurse practitioner. Chart review of patients aged 18 years or older with SCD followed by the Edmonton Hemoglobinopathy Clinic and who presented to MOU from November 2019 to December 2022 for management of VOC was completed. Information gathered included if the patient was on hydroxyurea at the time, investigations ordered, treatments administered, if NP or physician assessment was required, and disposition following the encounter. Encounters within 7 days were counted as one episode and assumed to be the same VOC event. Visits to ED for this cohort were counted and compared to the number of ED visits from 2016 to 2018. Results: 26 SCD patients had at least one MOU encounter for VOC or prophylaxis resulting in a total of 136 encounters (median 2, maximum 25). These accounted for 96 separate episodes of VOC (median 2, maximum 19), with a median of 1 encounter to MOU per episode (maximum 5). Patient demographics had a mean age of 32 years as of the beginning of the study (maximum 65, minimum 16) with 14 males (54%) and 12 females (46%). Patient diagnoses included 10 with HbSS (38%), 12 with HbSC (46%), 3 with HbSD (12%), and 1 with HbSB° (4%). 21 of 26 patients (81%) were on hydroxyurea at some point during this time period. IV fluids were administered in 129 encounters (95%), and pain medications were given in 64 encounters (47%), with opioid medications being given in 24 encounters (18%). 109 encounters had assessment by a nurse only (80%), while 24 were also assessed by a nurse practitioner (18%) and only 3 required assessment by a physician (2%). Patients were discharged home in 134 of 136 encounters (99%), with only 2 encounters resulting in assessment in ED. 70 of 96 episodes of VOC treated in MOU did not have presentation to ED within 30 days (73%). Total ED visits for this cohort decreased from 59 in 2016-2018 to 38 during the time of this study. Conclusion: Treatment of VOC in an outpatient setting was effective for assessment and treatment and decreased ED visits in our cohort. While retrospective, these results suggest outpatient treatment of VOC can be completed safely and efficiently in a shared infusion unit and may be generalized to other centres with outpatient IV infusion programs.

Gender moderates the association between posttraumatic stress disorder and mutual intimate partner violence in an emergency department sample.

Patients in emergency departments (EDs) constitute a diverse population with multiple health-related risk factors, many of which are associated with intimate partner violence (IPV). This paper examines the interaction effect of depression, posttraumatic stress disorder (PTSD), impulsivity, drug use, adverse childhood experiences (ACEs), at-risk drinking, and having a hazardous drinker partner with gender on mutual physical IPV in an urban ED sample. Research assistants surveyed 1037 married, cohabiting, or partnered patients in face-to-face interviews (87% response rate) regarding IPV exposure, alcohol and drug use, psychological distress, ACEs, and other sociodemographic features. IPV was measured with the Revised Conflict Tactics Scale. Interaction effects were examined in multinomial and logistic models. Results showed a significant interaction of gender and PTSD (odds ratio [OR] 3.06, 95% CI 1.21-7.23, p < 0.05) for mutual IPV. Regarding main effects, there were also statistically significant positive associations between mutual physical IPV and at-risk drinking (OR 1.73, 95% CI 1.07-2.77, p < 0.05), having a hazardous drinker partner (OR 2.19, 95% CI 1.35-3.55, p < 0.01), illicit drug use (OR 2.09, 95% CI 1.18-3.71, p < 0.01), ACEs (OR 1.23, 95% CI 1.06-1.42, p < 0.01), days of cannabis use past in the 12 months (OR 1.003, 95% CI 1.002-1.005, p < 0.001), and impulsivity (OR 2.04, 95% CI 1.29-3.22, p < 0.01). IPV risk assessment in EDs will be more effective if implemented with attention to patients' gender and the presence of various and diverse other risk factors, especially PTSD.

Early rule-out of major adverse cardiac events in acute chest pain patients using a risk score and self-reported computerised history taking

Abstract Introduction Risk scores, such as the History, ECG, Age, Risk factors, and Troponin (HEART) score, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol (EDACS-ADP), and Troponin-only Manchester Acute Coronary Syndrome (T-MACS), are recommended for the evaluation of acute chest pain patients. Obtaining a structured medical history by self-reported computerised history taking (CHT) may provide an automated and improved risk assessment in the emergency department (ED). Purpose We aimed to determine the diagnostic accuracy of three well-established acute chest pain risk scores using CHT to predict 30-day major adverse cardiovascular event (MACE). Methods Prospective cohort of clinically stable patients aged ≥18 years presenting with a chief complaint of chest pain and an ECG not indicating an acute coronary syndrome (ACS), at a tertiary hospital ED during 2017–2019. Medical histories were self-reported on a tablet using a CHT program (Clinical Expert Operating System, CLEOS), owned by a public university. With &amp;gt;17,000 decision nodes, CLEOS mimics a physician interview and tailors each interview depending on previous answers. Data acquired is in a binary structured format and can be used for input in clinical decision support systems. The HEART score, EDACS-ADP, and T-MACS were calculated from the CHT and the electronic health records (EHR). Relevant EHR data, including medical history, vital signs, and lab data, was extracted manually by the research staff in a predetermined standardised way. The EHR was subsequently reviewed for ACS and intervention procedure International Classification of Diseases (ICD) codes for any 30-day 3-point MACE. Results Of the 1,000 consecutive participants enrolled (mean age 55±17 years; 54% women), the HEART score, EDACS-ADP, and T-MACS could be calculated in 65%, 65% and 68%, respectively using only CHT acquired data. Main reasons for premature termination of the CHT were early discharge from ED or getting tired. A 30-day MACE occurred in 7.2% of the total population. The sensitivity, specificity, positive and negative predictive values of any 30-day MACE are presented in Table 1. The diagnostic accuracy for each risk score using CHT was similar to previous studies, where physician-collected data was used. Conclusions CHT can provide relevant risk scores in a majority of acute chest pain patients, and allow a safe and early rule-out of a 30-day MACE. The use of CHT may enable automation and improve the management of a large proportion of low-risk acute chest pain patients in the ED.Example of a question in the CHT program

Abstract 253: Impact of Gender and Marital Status on Door‐To‐Needle and Door‐To‐Puncture time and Acute Stroke Outcome

Introduction Delays in acute treatment of ischemic stroke have been associated with worse outcomes [1]. Women are more likely to present with atypical stroke symptoms than men, causing delay in pre‐hospital diagnosis and seeking medical attention [2‐3]. Additionally, women tend to be older at stroke onset and more likely to be living alone [4‐5]. Among patients presenting with acute stroke, women experience longer emergency department (ED) door‐to‐doctor and door‐to‐imaging (DIT) times, resulting in fewer interventions [6]. It is unclear if gender disparities in the timeliness of ED arrival and stroke assessment are compounded by gender differences in timeliness of treatment after patient arrival in the ED. Therefore, we sought to identify, if gender and marital status were associated with faster door‐to‐needle (DTN) and door‐to‐puncture (DTP) times. We hypothesized that married men would have the fastest DTN and DTP times, associated with female spouses being quicker to recognize traditional signs of stroke, calling 911 who can activate stroke alert, and therefore avoiding delay in acute care. Methods Our single‐center stroke database was queried for adults presenting to the ED with acute stroke between 1/1/2018‐1/30/2023. Patients were excluded if they had missing data on marital status or covariates. DTN and DTP times, as well as National Institutes of Health Stroke Scale (NIHSS) at discharge, were analyzed using quantile regression on sex, marital status (dichotomized as married vs. single), age, intervention (TPA alone, or thrombectomy±TPA), and NIHSS score at presentation. Results We identified 674 patients meeting inclusion criteria, of whom 31 were excluded due to missing data. In the remaining sample (N=643, median age 66yr), 25%/18% of patients were married men/women, respectively, and 22%/35% were single men/women. Median DTN time, DTP time, and discharge NIHSS were 36min, 79min, and 4, respectively. On multivariable analysis (Table), none of the outcomes were improved among married men relative to any other combination of sex and marital status. Conclusion Gender differences in knowledge of warning signs of stroke in community‐based studies and gender disparities in ED assessment did not translate into faster treatment “after” ED arrival based on gender or marital status. More work is needed to find out ways to accelerate care “after” ED arrival to have faster DTN and DTP time.

Analysis Of The External Cause Code Accuracy Case Of Injury In General Hospital PKU Muhammadiyah Bantul

The assignment of diagnosis codes and procedures must be done correctly to ensure the quality of medical records is met. What is often forgotten when giving a diagnosis code is the secondary code or external cause. This research aims to determine the recording, implementation and level of accuracy of external cause codes. Descriptive research method with a cross sectional design. The research sample was 48 injury medical record files. The research results showed that external cause information was documented on triage forms, emergency department assessments, initial adult inpatient nursing assessments, integrated patient progress notes, and discharge summaries. External cause coding is carried out by a coder with a medical record background in accordance with the SOP for coding implementation using electronic ICD-10 contained in SIMRS. The level of accuracy of the external cause code up to the 5th character (Category A) is 0%, the 4th character (Category B) is 38%, the 3rd character (Category C) is 27%, and the 1st character (chapter) (Category D) of 35%. The reason for the inaccuracy is because SIMRS does not accommodate coding up to the fifth character and the SPO does not yet indicate the officer's activity steps to determine up to the 5th character sub-category. It can be concluded that the accuracy of external cause coding at RSU PKU Muhammadiyah Bantul falls into the Fair criteria with an accuracy range of 20-40%.

Community healthcare appointments as an alternative to emergency department assessment: an exploration of family acceptability and preferences.

Pediatric emergency departments are overcrowded, in part due to many non-emergent visits. We aimed to assess the proportion of parents interested in leaving the pediatric emergency department (ED) prior to physician assessment if they could be offered a scheduled community healthcare appointment. We explored differences in care children received in the ED stratified by interest in a community healthcare appointment and parents' reasons when they were not interested. We conducted a 14-item survey within the pediatric ED at a Canadian tertiary care teaching hospital to assess parents' interest if a program offered community healthcare appointments and we determined preferred appointment characteristics. All parents presenting with children triaged as CTAS 2-5 who met eligibility criteria were approached by a research assistant prior to physician assessment. Surveys were paired with the medical chart outlining the care received. Descriptive statistics and a regression model were used to describe characteristics of families and care received among those who were and were not interested in a community healthcare appointment. In total, 403 surveys were completed. Overall, 236 participants (58.6%; 95% CI 53.8-63.4) were interested in a community healthcare appointment. In general, parents who were interested in a community healthcare appointment were younger and presented with younger children compared to those who were not interested. Among those interested, there was a preference to have the appointment with a pediatrician or family physician, timely access to an appointment, and appointments scheduled outside of regular business hours. Our study provides evidence that there is interest in an alternative care access model positioned to reduce pediatric ED congestion. We found that parents would be interested in leaving the pediatric ED in favor of a community healthcare appointment, provided it was with a physician and available in a timely manner.

Emergency department assessment and management of children with gastroenteritis

BackgroundAcute gastroenteritis is a major cause of morbidity and mortality in children. The aim of this study was to explore assessment and management of children aged between 6 and 48 months presenting to the emergency department (ED) with acute gastroenteritis. MethodsThis retrospective cohort study included 340 children aged 6–48 months. Data were collected by medical record audit for children presenting between 1 January and 31 December 2019. ResultsGeneral assessments were appropriate, specific dehydration assessment, blood pressure measurement and fluid balance chart documentation could be improved. Management of children with severe or no/mild dehydration was largely compliant with current recommendations: there was variability in management of children with moderate dehydration. There were no significant differences between Australian Aboriginal and non-Aboriginal children in terms of dehydration severity and pathology abnormalities, however there were differences in management strategies. ConclusionsED management of children with gastroenteritis was largely consistent with, or superior to, evidence-based recommendations. There was variability in the management of children with moderate dehydration and Australian Aboriginal children but it is unclear whether this is suboptimal or patient specific care. This study has highlighted areas for further research in this unique context.

A systematic review of the applicability of emergency department assessment of chest pain score-accelerated diagnostic protocol for risk stratification of patients with chest pain.

The emergency department assessment of chest pain score-accelerated diagnostic protocol (EDACS-ADP) are commonly used for risk stratification in undifferentiated patients with acute chest pain. This systematic review aimed to investigate EDACS-ADP for risk stratification of emergency department (ED) patients with chest pain. The PubMed, Web of Science, Medline, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched for related studies without restrictions on the publication year. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias, and Stata 16.0 was used to determine the combined sensitivity, specificity, positive diagnostic likelihood ratio (DLR), and negative DLR. Twelve studies comprising 14 290 patients were identified. Of these, 7537 (52.74%) patients were considered low risk, and 67 (0.89%) had major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular death within 30 days of the patients' ED presentation. EDACS-ADP showed a combined sensitivity of 0.97 (95% confidence interval [CI]: 0.95-0.99); specificity, 0.58 (0.53-0.63); positive DLR, 2.34 (2.08-2.63); negative DLR, 0.04 (0.02-0.09); diagnostic odds ratio, 53.11 (26.45-106.63); and summary receiver operating characteristic area under the curve, 0.83 (0.79-0.86). Despite the large statistical heterogeneity of the results, EDACS-ADP identified a considerable number of low-risk patients for early discharge, with a specificity >50% and an incidence of MACE within 30-days of patients' ED presentation <1%. Thus, it is a useful tool with a potential for clinical application.

Understanding the Clinical Profile and Hospitalisation Patterns of Residents From Aged Care Facilities: A Regional Victorian Hospital Study.

Introduction Residents of residential aged care facilities (RACFs) are typically frailer than their community-dwelling counterparts. They often present to the emergency department (ED) with varied health issues, frequently leading to hospital admissions. These admissions can exacerbate patient frailty and strain the healthcare system. Despite global efforts to reduce ED presentations from RACFs, effective strategies still need to be discovered. This study examines the clinical profile and hospitalisation patterns of RACF residents in a regional Victorian town. Aims The study aimed to assess the prevalence of ED presentations and representations from RACFs, investigate the causes and outcomes of hospital admissions stemming from these presentations, and evaluate the prevalence of documented (advanced care directives) ACDs within this patient cohort. Methods Following ethical approval, we conducted a retrospective analysis of 467 ED presentations from 310 RACF patients admitted to Goulburn Valley Health's (GVH) ED from January to June 2022. We collected and examined data on demographics, ACD existence, ED presentation characteristics, and hospital admissions, classifying admission reasons into eleven groups. Statistical analysis was performed with GraphPad Prism and IBM SPSS, using inferential tests and logistic regression to assess readmission odds at a significance threshold of p<0.05. Results Our study encompassed 310 patients from multiple RACFs, yielding 467 ED presentations. These constituted 2.28% of total ED visits and 9.85% of those aged 65 and above. Most of the cohort were females (59.4%), aged between 79 and 91. About 98 patients presented multiple times, and 48.2% of presentations led to hospital admissions, with 6.2% of admitted patients succumbing during the hospital stay. A documented ACD was absent in 42.9% of the cohort. Statistically significant results include a correlation between male sex and an increased frequency of ED representations (p=0.0422) and a longer ED stay duration for admitted patients (p<0.0001). No significant associations were found between ACD presence and ED representations, ACD and sex, or between age and duration of stay in the ED. Age did not differ significantly among patients with single or multiple presentations or between patients with or without ACD. Regarding fall-related presentations, no significant sex-based difference in admission rates was found. The duration of stay between surgical and medical admissions was also statistically indifferent. Conclusion Our study highlights the significant utilisation of ED services by RACF residents, mainly males. The substantial percentage of these presentations resulting in hospital admissions underlines the critical nature of these visits. The absence of ACD in a significant portion of the cohort and the lack of its influence on the frequency of representations signal the need for further exploration. The results underline the ongoing challenge of meeting the complex healthcare needs of RACF residents and emphasise the importance of gender-specific interventions and efficient hospital utilisation strategies to optimise healthcare delivery in this population. Future studies should further investigate the underlying reasons for these findings to inform targeted strategies for reducing unnecessary ED visits and hospital admissions. Furthermore, fall-related presentations necessitate comprehensive ED assessments and integrated management approaches.

Delirium, confusion, or altered mental status as a risk for abnormal head CT in older adults in the emergency department: A systematic review and meta-analysis

BackgroundAltered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT). MethodsA systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status. ResultsThe search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status. ConclusionWe did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.

Time ratio disparities among ED patients undergoing head CT.

To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities. This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups. A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001). Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.