Busy Emergency Department Research Articles

Ecstasy and related drug consumption and the effect on emergency department resource use

BackgroundEcstasy and other recreational related drug use and substance related presentations to the emergency department (ED) are increasing. The aim of this study was to identify, quantify, and describe the ED resources used to care for patients diagnosed with ecstasy and related drug (ERD) use. MethodA retrospective case study design. ResultsEighty-nine patients (89%) needed one to one (n=25) and/or one to two nursing care (n=83). Security presence was required for 37 patients (37%) and the Emergency Psychiatric Service team reviewed 29 patients (29%). Most patients (n=80, 80%) received an Emergency Short Stay Unit admission, but continued to receive care in the ED, and were not transferred to the short stay unit (n=74, 92.5%). Most patients (n=86, 86%) were discharged home, after 5hr 49mins (median) in ED. ConclusionExtensive human resources were required to care for patients diagnosed with ERD use. Nursing staffing levels required to care for this patient cohort during times of peak presentations should be reviewed. It is important the government acknowledges the National Emergency Access Target is not suitable for all presenting patients. A dedicated model of care is recommended to support care requirements and reduce pressure on busy EDs.

Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis.

Provider-performed endocervical sampling (PPES) in the diagnosis of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) may be difficult to perform in a busy emergency department (ED) due to patient preference, availability of the pelvic examination room, or provider availability. Our objective was to assess if self-obtained vaginal swabs (SOVS) were noninferior to PPES in the ED diagnosis of NG/CT using a rapid nucleic acid amplification test (NAAT). We conducted a prospective observational cohort study in a single ED. Participants were adult female English- and Spanish-speaking patients in whom the ED provider felt that NG/CT testing was warranted. Each patient had SOVS and PPES performed. For SOVS, a research associate reviewed a one-page handout describing the procedure but gave no other assistance. Patients answered survey questions regarding acceptability of SOVS and symptomatology. We established a minimum sensitivity of 90% for SOVS to be considered clinically noninferior to standard PPES. A total of 533 patients completed enrollment and answered survey questions, 515 of whom had laboratory results for both SOVS and PPES. There were 86 patients with a positive result: 29 with NG, 47 with CT, and 10 with coinfection. SOVS had a sensitivity of 95% (95% confidence interval= 88% to 99%) for the detection of NG/CT when compared to PPES. SOVS were felt to be an acceptable collection method in 93% of patients and 75% preferred SOVS to PPES. SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability.

The Impact of Facility Layout on Service Worker Behavior: An Empirical Study of Nurses in the Emergency Department

Problem definition: We study the impact of service facility layout on how service workers organize their tasks. We focus on the hospital emergency department (ED) as a service setting in which nurses (servers) have discretion over how they interact with patients (customers) in a facility that introduces significant heterogeneity in necessary walking distance. Academic/practical relevance: Prior studies on facility layout in operations have largely focused on the direct effect of transit times on reduced productivity. We extend this work to show how skilled service workers such as nurses adapt their work behavior to enhance their productivity in response to facility layout constraints. Methodology: To study this empirically, we utilize a unique data set consisting of infrared nurse location tracking data, patient electronic medical record data, bedside patient call data, and the architectural floor plan of a large academic ED. Results: Nurses working in a busy ED appear to reduce their walking distance by batching their tasks to distant patient rooms. Although the patients in these rooms receive the same amount of care time, this behavior results in longer wait times between nurse visits and more nurse call button activations, but it does not compromise the overall quality of care delivered. Nurse call button use is linked with poor patient satisfaction and interrupts nurse workflow. Managerial implications: These findings show that even in services, facility layout can lead to servers using task timing discretion in ways that help the server but lead to a additional waiting time for the customer. We propose countering the negative effects of distance-based task batching through proactive nurse rounding and operational transparency.

Contact tracing of staff in the emergency department during the COVID-19 pandemic.

Contact tracing of staff in the emergency department during the COVID-19 pandemic.

So You Think This Baby Has Appendicitis? The Subtle Clues and Deceptive Signs

Diagnosing appendicitis in infants is challenging due to varied and heterogenous presentations. Whilst the condition is uncommon, the consequences of missing this in a busy Emergency Department (ED) can be catastrophic. We report an 8-month-old infant who presented to ED with a brief history of reduced feeding, lethargy and vomiting with normal observations. Excessive crying was noted when the child was supine, he was consolable when placed prone. Due to these paroxysms of crying which varied with position, investigations were commenced. He had a good clinical outcome. A high degree of suspicion is needed in preverbal children. Clinical examination, observation of the behaviour of the child and parental concern remain key to diagnosis. Through this paper we aim to explore the clinical conundrum of making the diagnosis in this age group and the modalities which help in decision making.

Basic types of the first-day glycemia in acute myocardial infarction: Prognostic, diagnostic, threshold and target glycemia

We described the importance of stress hyperglycemia (SH) in critical illnesses and their evaluation in the emergency department (ED) and coronary care unit (CCU). Hyperglycemia is found in over half of the patients with suspected acute myocardial infarction (AMI). SH can be used for several purposes in AMI. Receiver operating characteristic curves are needed to find optimal cut-offs to divide blood glucose levels associated with good from bad prognosis in AMI. There is a need for a consensus for pragmatic classification of first day glycemia in order to be useful in a busy ED and CCU.

Risk prediction using the National Early Warning Score and the Worthing Physiological Scoring System in patients who were transported to the Intensive Care Unit from the Emergency Department: A cohort study

ObjectivesThe aim of this study was to assess the value of the National Early Warning Score and Worthing Physiological Scoring System for predicting changes in the condition of critical cases during transfer from the emergency department to the intensive care unit. MethodsThis prospective single-centre study was conducted at a 1759-bed hospital in Beijing. We recorded the vital signs in the cases before leaving the emergency department and their changes in condition during transit. ResultsA total of 258 critically ill cases were included. Forty-four cases (17.05%) exhibited changes in their condition during transit. Compared with cases with NEWS ≤ 5, cases with NEWS > 5 were more likely to experience changes with an OR of 5.744 (95% CI 2.888–11.426). Compared with cases with WPS ≤ 2, cases with WPS > 2 were more likely to experience changes with an OR of 7.217 (95% CI 3.575–14.569). The difference between the areas under the curve of the NEWS (0.751 ± 0.045) and the WPS (0.736 ± 0.045) was not statistically significant (P = 0.4518). ConclusionIn our study, the Worthing Physiological Scoring System and National Early Warning Score both exhibited good discriminatory power, but the Worthing Physiological Scoring System is simpler to use and more suitable for use in a busy emergency department.

The burden of migraine on acute and emergency services in a London teaching hospital.

There is a lack of data on the burden of primary headache disorders such as migraine on emergency services. Existing data relies on a coding of "headache", which encompasses both primary and secondary headache of all causes; for example, subarachnoid haemorrhage. Guy's and St Thomas' NHS Trust in London is one of the UK's busiest emergency departments with 150,000 attendances per year. Our aim was to assess the healthcare resource utilisation of primary headaches, in particular migraine, in acute medical services. We conducted an audit of all adult presentations to the emergency department of Guy's and St Thomas' Hospitals which were coded as "headache" over the first 6 months of 2018. We reviewed the initial diagnosis at presentation and also at discharge, investigations and outcome. Of 78,273 attendances to the emergency department, there were 976 presentations to the emergency department with "headache" as their primary complaint. "Migraine" was the most frequent of all diagnoses, accounting for 30% of all headache presentations and 25% of headache admissions. We calculated the cost of admitting and investigating migraine as £131,250 over the 6-month period. Emergency admissions for migraine represent an avoidable cost and burden for both the hospital and the migraineur. This data informs us about the need to develop better care pathways for migraine in the community and to improve headache education for physicians and patients.

Applying Bowen Theory to Psychiatric Assessment and Disposition in the ED.

A number of variables have been shown to influence whether an individual who experiences an emergency psychiatric assessment is admitted to a psychiatric hospital. This study focused on the theoretical orientation of the assessing clinician as a possibly influential variable. The theoretical orientation being studied was Bowen family systems theory or Bowen theory (Bt). Overall the Bt perspective looks at the family as the primary crucible that generates symptoms but at the same time as the natural unit and the best built-in resource to deal with those symptoms. This study examined whether the theoretical orientation of the nurse psychiatric assessor would affect her inpatient admission rate of patients seen for psychiatric evaluation in an emergency department (ED). A clinician/researcher with extensive experience applying Bt in clinical practice worked in a Crisis Management Service providing psychiatric evaluation and disposition in a busy community hospital ED. Given Bt's emphasis on the system rather than individual pathology, the clinician researcher hypothesized that her psychiatric hospitalization rate would be lower than the other clinical nurse specialists. A retrospective chart review analyzed 1 year of cases from all referrals that might have resulted in psychiatric hospitalizations (n = 1,801). The clinician/researcher's psychiatric hospitalization rate was significantly lower (p = .004) than the other clinicians. An approach to psychiatric assessment in the ED applied a Bt perspective in a way that significantly reduced psychiatric hospitalizations.

Predictors of epinephrine undertreatment in anaphylaxis—the experience of a busy North American tertiary care pediatric emergency department

Anaphylaxis, a potentially fatal allergic reaction with an increasing incidence and severity continues to be underdiagnosed and undertreated.1 Intramuscular (IM) epinephrine is the first-line treatment in any age group,1 and delay in administration is associated with a higher risk of fatality.2 Rates of epinephrine under treatment in the outpatient setting and in the emergency department (ED) range between 25% and 60%,3-6 even following intervention programs.6 Predictors for epinephrine undertreatment have been poorly studied.

Increasing consultant-level staffing as a proportion of overall physician coverage improves emergency department length of stay targets

ObjectivesOne goal of Emergency Department (ED) operations is achieving an overall length of stay (LOS) that is less than four hours. The goal of the current study was to assess for association between increasing number of on-duty EM Consultants and LOS, while adjusting for overall (all-grade) on-duty emergency doctors’ numbers and other operational factors.MethodsThis was a retrospective analysis of three years (2016–2019) of data, employing a unit of analysis of 3276 eight-hour ED shifts. The study was conducted using a prospectively populated ED database in a busy (annual census 420,000) Middle Eastern ED with staffing by Consultants and multiple non-Consultant grades (Specialists, fellows, and residents). Using logistic regression, the main predictor variable of “on-duty Consultant n” was assessed for association with the study’s primary (dichotomous) endpoint: whether a shift’s median LOS met the target of < 240 min. Linear regression was used to assess for association between on-duty Consultant n and the study’s secondary (continuous) endpoint: median LOS for the ED shift.ResultsMultivariate logistic regression adjusting for a number of operations factors (including total EP on-duty complement) identified an association between increasing n of on-duty Consultants and the likelihood of a shift’s meeting the 4-h ED LOS target (OR 1.27, 95% CI 1.20 to 1.34, p < .0001). Multiple linear regression, which also adjusted for total on-duty EP n and other operational factors, also indicated LOS benefit from more on-duty Consultants: each additional on-duty Consultant was associated with a shift’s median LOS improving by 5.4 min (95% CI 4.3 to 6.5, p < .0001).ConclusionsAt the study site, in models that adjusted for overall on-duty EP numbers as well as myriad other operational factors, increasing numbers of on-duty Consultants was associated with a statistically and operationally significant reduction in ED LOS.

Improving Length of Stay Using a Dyspnoea Service for Undifferentiated Dyspnoea—A Single Centre Experience

Acute dyspnoea can prove to be a frequently diagnostic dilemma for emergency and internal medicine physicians. Our busy emergency department often uses tests with low specificity such as D-dimer and troponin levels, often extending the patients’ stay in ED without providing a unifying diagnosis. Our institution at The Canberra Hospital has created a dyspnoea service to address this issue.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal.

PurposeAcute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.MethodsWe conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.ResultsThe AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43–4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11–3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362–6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.ConclusionThe current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.

The time is “now” for rapid PCR testing for influenza in clinical practice

El Feghaly et al at Children's Mercy Kansas City presented a brief survey to providers in their emergency department and urgent care centers who placed an order for influenza RT-PCR test, asking their estimation of probability of the patient having influenza and their intentions to manage, including therapy. They also captured actual management once the results were available. Overall, about one-half of tests were positive. Clinical suspicion was not a predictor of test results, the positivity rate being 40% if suspicion was low and 57% if high. Test results changed clinicians' management (eg, for further tests/imaging, antibiotic/antiviral therapy) in 44% of influenza PCR-positive cases and in 93% of PCR-negative cases. The net cost savings in avoiding antiviral therapy alone offset the cost of PCR testing compared with rapid antigen testing for influenza. It's a new world. With PCR testing for influenza being the first highly sensitive and specific test, we can accurately discern the etiology of the patient's illness. As the flu season looms, not only are there ramifications of testing for optimizing treatment for influenza and saving resources, but because of pandemic SARS-CoV-2 there is an urgent need to know who has what. With clinical ability to diagnose influenza as shown in this study to be no better than a coin toss, and with most SARS-CoV-2 infections in children not discernible by clinical manifestations, we face a nightmare that includes managing families and teachers and school children, if there is concurrent community activity of both viruses. Can we tamp down the nightmare? Absolutely. 1) Promote, insist, and ensure influenza vaccination (unless a valid contraindication exists) of every person 6 months of age or older – both to reduce illness as well as the seasonal burden of influenza. In another study published in this volume and conducted across 6 countries, Goldman et al showed that there may be increased opportunity. Questioning ∼2400 parents bringing a child to an emergency department earlier in the COVID-19 pandemic about their plan to have their child immunized against influenza in the Fall, almost 30% who had not done so last year planned to do so in 2020. We must capitalize on the moment, offer, and facilitate vaccinations. 2) Continue optimal behaviors to reduce SARS-CoC-2 transmission and acquisition. 3) Sort out the logistics to be able to use the powerful technology of PCR testing in everyday clinical practice in order to accurately determine etiology of respiratory illness at least for these 2 viruses. Articles pages 87 and 271 ▸ Impact of Rapid Influenza Molecular Testing on Management in Pediatric Acute Care SettingsThe Journal of PediatricsVol. 228PreviewTo measure the impact of rapid influenza real-time qualitative reverse transcriptase polymerase chain reaction (RT-PCR) on patient management in busy pediatric emergency department (ED) and urgent care clinic settings. Full-Text PDF Willingness to Vaccinate Children against Influenza after the Coronavirus Disease 2019 PandemicThe Journal of PediatricsVol. 228PreviewTo determine factors associated with parents who plan to vaccinate their children against influenza next year, especially those who did not vaccinate against influenza last year using a global survey. Full-Text PDF

The Pause: A Second Chance for a Meaningful Connection.

I often reflect on how small this world is, or how meeting a new person can forever change your life. This happened in September 2018 when I met two amazing emergency department nurses from Baltimore at a conference in Ohio. Little did I know at the time, but we had much more in common than our shared specialty of Emergency Medicine. They were sharing their outcomes after introducing "The Pause," a short verbal reflection and silent moment performed after a patient death meant to recognize and acknowledge the patient and the care team, at their busy Emergency Department. While intrigued, I also knew we had previously tried implementing this in our own ED without consistency or success.

Risk prediction models to guide antibiotic prescribing: a study on adult patients with uncomplicated upper respiratory tract infections in an emergency department

BackgroundAppropriate antibiotic prescribing is key to combating antimicrobial resistance. Upper respiratory tract infections (URTIs) are common reasons for emergency department (ED) visits and antibiotic use. Differentiating between bacterial and viral infections is not straightforward. We aim to provide an evidence-based clinical decision support tool for antibiotic prescribing using prediction models developed from local data.MethodsSeven hundred-fifteen patients with uncomplicated URTI were recruited and analysed from Singapore’s busiest ED, Tan Tock Seng Hospital, from June 2016 to November 2018. Confirmatory tests were performed using the multiplex polymerase chain reaction (PCR) test for respiratory viruses and point-of-care test for C-reactive protein. Demographic, clinical and laboratory data were extracted from the hospital electronic medical records. Seventy percent of the data was used for training and the remaining 30% was used for validation. Decision trees, LASSO and logistic regression models were built to predict when antibiotics were not needed.ResultsThe median age of the cohort was 36 years old, with 61.2% being male. Temperature and pulse rate were significant factors in all 3 models. The area under the receiver operating curve (AUC) on the validation set for the models were similar. (LASSO: 0.70 [95% CI: 0.62–0.77], logistic regression: 0.72 [95% CI: 0.65–0.79], decision tree: 0.67 [95% CI: 0.59–0.74]). Combining the results from all models, 58.3% of study participants would not need antibiotics.ConclusionThe models can be easily deployed as a decision support tool to guide antibiotic prescribing in busy EDs.

The Hidden Burden of Community Enteral Feeding on the Emergency Department.

Enteral feeding tubes are associated with their most serious complications in the days and weeks after insertion, but there are limited published data in the literature on late complications and the implications for the healthcare service. This is a retrospective observational study of attendances to a UK hospital emergency department (ED), with enteral tube complications as the primary reason for attendance. Over 24 months, 139 attendances were recorded. Dislodged tubes and blocked tubes accounted for the majority of complications and subsequent admissions, with a mixture of enteral tube types being associated with both. Thirty-five percent of patients were admitted, and the average healthcare cost per attendance was $1071. Enteral tube complications can place a hidden burden on the patient, the ED, and healthcare costs. More work on education and supporting caregivers to resolve problems themselves could reduce the burden on busy EDs.

Reducing Blood Culture Contamination; a Quality Improvement Project in Emergency Department

Background: Blood culture is an important investigation in diagnosing sepsis. Positive culture helps to tailor therapy and is crucial in antimicrobial stewardship (AMS). However, positive blood culture does not always denote a bloodstream infection. Sometimes, false-positive results occur because of contamination from organisms outside the bloodstream, leading to significant negative consequences to patient treatment decisions and financial implications. Rates of blood culture contamination vary widely (0.6%–6%) between organizations, and although it is very difficult to eliminate contamination, it can be minimized. Our hospital group has multiple sites including emergency departments (EDs). We have been intermittently monitoring blood culture contamination rates since 2008, which decreased from 6.8% to 4.8% in 2009 but remained static when audited in 2010, 2012, and 2015. Objectives: To reduce our blood culture contamination rate further by targeting 2 busy EDs and by introducing continuous surveillance of blood culture contamination across 3 hospitals beginning in April 2016. Methods: In 2015, for the first time, blood culture contamination rates for both EDs, based in 2 different hospitals, were calculated. The ED results were communicated to the healthcare workers (HCWs), who agreed to establish a continuous surveillance of blood culture contamination and to participate in a reduction plan. Competency training was conducted according to training needs analysis. For example, phlebotomists were trained to ensure the use of the appropriate blood culture kit and educational sessions were tailored to staff groups. The blood culture contamination rate was monitored from April 2016 to March 2019 for 3 hospitals and both EDs to determine the impact of various measures introduced during this time. Results: In 2015, contamination rate of the 3 hospitals was 4.07%, and 10.2% of total blood cultures flagged positive. Also, 25% of blood cultures were requested from Eds, but these samples comprised 54% of the total contamination. The contamination rates for EDs A and B were 7.4% and 10.6%, respectively, which were significantly higher than the overall rate. From April 16 to March 19, there was 22% increase in total blood cultures performed. Results were analyzed quarterly. In total, 8,525 blood culture sets were received in January–March 2019; of these, the EDs contributed 2,799 sets (32.8%). The total blood culture contamination rate in January–March 2019 decreased to 3.1%. Both EDs A and B showed decreases in their contamination rates to 5.5% and 7.4%, respectively, in 2018–2019. The quarterly decreases were 5.2% and 4.9% in January–March 2019. Conclusions: The emphasis on the sepsis pathway probably led to year-on-year increases in total blood culture sets. Both ED blood culture contamination rates decreased. Consistent efforts in education, training, ensuring competency to various HCW groups, and provision of adequate blood culture kits are important for sustaining these improvements.Funding: NoneDisclosures: None

258 Detection of Delirium among Older Adults in the Emergency Department Through the Utilization of 4AT

Older adults make more than 20 million emergency department (ED) visits annually, accounting for over 15% of all ED visits. Among older adults, change in mental status or delirium is the frequent cause for presentation to the ED. Delirium accounts for 11-42% of hospitalizations contributing $152 billion to health care expenditures annually in the US. Overall detection of delirium in ED is poor, with ED providers missing delirium in up to 75% of cases. The goal of this study was to assess the detection of delirium among older adults through the utilization of 4AT in a high flow, high acuity ED. We conducted a single-center, retrospective chart review in a busy academic ED with 67,000 total annual visits, and 24% geriatric (age ≥ 65 y) visits, from 9/24/2019 to 5/24/2020. Prior to the study period, delirium assessment tool- 4AT was built into EMR and appropriate workflow was designed. 4AT was performed at the time of triage on patients meeting following criteria: 1) Above age 65 years old with presenting complaint of altered mental status or 2) Above age 80 years old with any clinical presentation. Delirium was defined as: Positive 4AT score regardless of chief complaint to ED. A positive 4AT score was defined as 4 or greater. A total of 2,680 eligible patients were assessed during the defined study period. 1, 596 patients underwent 4AT and in 1,084 patient 4AT was not performed. A positive 4 AT was found in 300 individuals, regardless of presenting condition. Among individuals presenting with altered mental status (according to the 4AT screening question), a positive 4AT was found in 176 individuals. A positive 4AT was found in 124 individuals not originally presenting with complaint of altered mental status (according to the 4AT screening question). Overall delirium detection rate via 4AT was found to be 18.96%.Utilization rate of 4AT for eligible patients was around 60%. Previous studies have suggested use of 4AT for rapid delirium assessment in an ED because of its ability to be performed quickly- approximately 2 minutes- and is the only scale affording high sensitivity and specificity in older adults with and without dementia. Although completed in Irish and Canadian studies, validation of the use of 4AT in an US ED environment has not yet been completed. In our study, utilizing 4AT we find a delirium detection of 18.96 %( 300) which is consistent with previous studies of rates of delirium among older adults in an ED setting. We also discovered that 7.7%(124) individuals were found to have a positive 4AT despite not originally presenting with altered mental status, indicating cases of delirium that may have been missed if a delirium evaluation (4AT)had not been completed. This study also highlights challenges in implementing delirium screening/assessment in fast-paced ED environment.

249 The Impact of an Electronic Medical Record Alert on Recognition and Referral of High-Risk Elders in the Emergency Department Setting

Older patients frequently utilize Emergency Departments (ED). Multiple comorbidities, polypharmacy, impaired mobility (falls), changes in mentation (delirium, dementia) and poor social support often contribute to ED visits. Traditional assessment tools, such as ISAR, to identify high-risk geriatric patients can be difficult to implement in a high volume, high acuity ED setting. We examined the impact of an electronic medical record (EMR) best-practice alert (BPA), on recognition and referral of high-risk older patients in the Emergency Department (ED) who could potentially benefit from geriatric evaluation. Retrospective case control study in a busy academic ED with 67,000 total annual visits, and 24% geriatric (age ≥ 65 y) visits, from October 1, 2019 to May 31, 2020. In the initial program (10/1/19-3/30/20), ED providers were educated about high-risk geriatric conditions and an EMR BPA alerted ED providers to a positive (+) triage delirium screen. Starting 3/31/20, an enhanced BPA used EMR-automated recognition that also included age ≥80y, fall complaint, documented dementia history, polypharmacy (≥ 10 medications recorded), or high ED utilization (>5 visits in 1 year) in addition to the (+) delirium screen. A modified Delphi method was used to select these additional high-risk geriatric characteristics. Frequency of BPA notification and ED or ED-observation unit geriatric consultation (summed as comprehensive geriatric assessment, CGA) are reported for initial and enhanced BPA cohorts. Data was abstracted from the electronic medical record. The difference between initial and enhanced BPA encounters is reported. Analysis used SAS studio (v9.4, Cary, NC). 95% CI and p-values are reported. 7,718 geriatric patients were seen during the initial program; 1,836 were seen during the enhanced BPA program. Mean age in the initial cohort was 74.9 years (95% CI, 74.7, 75.0) and 75.6 years (95% CI, 75.1, 76.0) in the enhanced BPA cohort (p=0.002). % Female was 53.0% and 52.9%, respectively (p= 0.95). Unenhanced BPA alerts in the initial program averaged 53/month (range 45-67). BPA alerts in the enhanced program averaged 699/month. In the initial cohort, 318 (4.1%) BPA alerts led to 30 CGA. 303 (4.1%) patients for whom the initial BPA did not fire were also referred for CGA. Overall, during the initial period, 333 (4.3%) patients had CGA. The enhanced BPA resulted in 1398 (76.1%) alerts and 82 (5.9%) CGA. 14 (3.2%) BPA-negative patients were also referred for CGA. Overall, during the enhanced-BPA, 96 (5.2%) patients had a CGA. After the BPA enhancement, the proportion of geriatric evaluations increased a relative 21% (4.3% to 5.2%, p=0.09). Overall CGA referrals averaged 56/month during initial BPA and 48/month in the enhanced period. Of note, due to COVID-19 impact, overall ED volume declined 29% and geriatric ED visits declined 30% during the enhanced BPA period. This single-site study demonstrates that the EMR can be used to identify high-risk elders. An enhanced automated EMR BPA increased both ED provider alerts and, more importantly, geriatric evaluations in high-risk older ED patients. An EMR-based automated alert can be a useful adjunct to increase referrals and geriatric evaluations in the ED setting for this at-risk population.