Emergency Department Care Research Articles

Suicide Prevention and Telehealth in Children's Hospital Emergency Departments.

Suicide is a leading cause of death among adolescents. Emergency department (ED) visits for mental health concerns are rising, and telehealth is increasingly used to provide emergency mental health care. We conducted a national survey to describe suicide prevention practices and tele-mental health care in children's hospital EDs. We conducted a cross-sectional survey of leaders at all 52 US EDs affiliated with dedicated children's hospitals (ie, hospitals that provide care only to children) to describe use of tele-mental health care and suicide prevention practices. Leaders from 41 EDs completed the survey (79% response rate). Tele-mental health care was used in 23 EDs (56%); there were no differences in ED structural characteristics between institutions with telehealth versus without telehealth. Among responding EDs, 40 (98%) reported they screen for suicide risk, and 29 (71%) reported they use a standardized approach to suicide prevention discharge planning. Risk reduction practices conducted at many but not all EDs included assessment of access to lethal means (n = 31, 86%), counseling on reduction of access to lethal means (n = 30, 73%) and providing patients with a list of professionals or agencies that they can contact in a crisis (n = 35, 85%). There were no differences in use of suicide prevention practices at EDs with versus without telehealth (P > 0.1 for all). Approximately half of children's hospital EDs use tele-mental health care, and hospitals with versus without tele-mental health care report similar rates of suicide prevention practice use. Opportunities exist to increase use of discharge safety practices.

Severe Maternal Morbidity and Postpartum Care: An Investigation Among a Privately Insured Population in the United States, 2008-2019.

Objective: This study examines postpartum health care utilization among women with severe maternal morbidity (SMM) subtypes (e.g., blood transfusion, renal), focusing on both early (within 7 days) and late (8-42 days) postpartum periods. By including outpatient visits alongside inpatient and emergency department (ED) visits, the study offers a comprehensive view of postpartum health care needs among women with SMM. Methods: This retrospective cohort study used data from Optum's de-identified Clinformatics® Data Mart Database from 2008 to 2019. The primary outcomes were early and late postpartum inpatient readmissions, early and late ED visits, and outpatient care within 42 days after delivery. Multilevel logistic regression models were used to estimate the association between SMM subtypes and postpartum readmission, ED, and outpatient care. Results: Except for hemorrhage, most SMM subtypes increased the postpartum odds of health care utilization. Women with other medical SMM (e.g., puerperal cerebrovascular disorders or sickle cell disease with crisis) had 2.9 times the odds (odds ratio [OR]: 2.87, 95% confidence interval [CI]: 1.30-6.34) of experiencing early readmissions compared with those without other medical SMM. Women with sepsis had 4.5-fold elevated odds (OR: 4.53, 95% CI: 2.48-8.28) of late readmission, a 1.9-fold increased odds (OR: 1.85, 95% CI: 1.12-3.04) of early ED visits, and over a 2-fold increased odds (OR: 2.27, 95% CI: 1.67-3.08) of postpartum outpatient visits compared with those without sepsis. Conclusion: This study reveals that certain SMM subtypes significantly increase postpartum health care utilization, emphasizing the need for further research and interventions to improve outcomes for affected women.

Characterizing Emergency Department Disposition Conversations for Persons Living With Dementia: Protocol for an Ethnographic Study.

Almost 40% of persons living with dementia make an emergency department (ED) visit each year. One of the most impactful and costly elements of their ED care is the decision to discharge or admit them to the hospital-the "disposition" decision. When more than one reasonable option exists regarding a health care decision, such as the decision to admit or not, it often requires a complex conversation between patients, care partners, and ED providers, ideally involving shared decision-making. However, little is known about how these conversations are conducted and the real-world context in which they take place. Best practices in ED communication and shared decision-making for persons living with dementia and their care partners are limited. This study aims to characterize current practices in ED disposition conversations for persons living with dementia and their care partners, informed by perspectives from patient and care partner participants. This study will use an ethnographic design, including direct observation methods with a semistructured data collection tool to capture the ED encounter for up to 20 patient and care partner dyads, including all discussions about dispositions. Follow-up qualitative, semistructured interviews will be conducted with persons living with dementia and their care partners to explore specific observations made during their ED encounter, and to gain insight into their perspective on their role and elements of decision support used during that conversation. Data collection was initiated in October 2023, with 13 dyads recruited and observed as of July 2024. This study is expected to be completed by December 2024. Novel methods can offer novel insights. By combining direct observation and follow-up interviews about an ED visit, our study design will provide insights into how ED disposition occurs in real-world settings for persons living with dementia. Findings can inform more patient-centered interventions for disposition decision-making. DERR1-10.2196/65043.

The experiences of trans (binary and non-binary) people accessing emergency department care in Australia: A grounded theory study

BackgroundThis study aimed to explore the experiences of trans (binary and non-binary) people accessing emergency department care in Australia. MethodThis qualitative descriptive study utilised a grounded theory approach. Seven people who identified as trans were recruited through social media and trans support groups. Individuals participated in an in-depth narrative interview. Interview transcriptions were analysed using a constant comparative approach. ResultsFollowing thematic analysis, four key themes were identified: 1. identity; 2. clinical care; 3. communication; and 4. perceptions of health professional education, beliefs and experience in caring for trans people. ConclusionThis study is the first in Australia to explore the experiences of trans people utilising emergency department services. The findings of this study are similar to international data whereby the delivery of gender affirming care in emergency departments is inconsistent, health professionals are perceived as poorly educated and gender identity is inadequately recognised.

Self-Efficacy in Disaster Preparedness: Insights from Nurses in Emergency and Intensive Care Units

Self-efficacy is a critical factor influencing nurses' performance in disaster scenarios, particularly in high-pressure environments like Emergency Departments (ED) and Intensive Care Units (ICU). This study aimed to evaluate the self-efficacy of nurses in disaster preparedness and identify its key predictors, including demographic characteristics, training experience, and professional factors. A cross-sectional survey was conducted among 185 nurses working in the ED and ICU of three hospitals in Yogyakarta, Indonesia. Data were collected from January to February 2024 using a structured questionnaire that included the Disaster Response Self-Efficacy Scale (DRSES). Descriptive statistics summarized demographic data and self-efficacy scores. Inferential analyses, including t-tests, ANOVA, and multiple regression, were performed to explore relationships between self-efficacy and potential predictors, with statistical significance set at p < 0.05. Disaster training experience emerged as the strongest predictor of self-efficacy (β = 0.65, p < 0.001), with nurses who underwent regular training demonstrating significantly higher confidence. Years of experience (β = 0.48, p = 0.01) and age (β = 0.25, p = 0.04) were also positively associated with self-efficacy. However, gender, education level, and marital status showed weak and non-significant correlations (r = 0.12–0.18, p > 0.05). Correlation analysis reinforced the importance of disaster training (r = 0.65, p < 0.001) and professional experience (r = 0.48, p = 0.01) in shaping self-efficacy. The findings underscore the importance of regular disaster training and leveraging professional experience to enhance self-efficacy among ED and ICU nurses. Policymakers and hospital administrators should prioritize targeted training programs to build a resilient nursing workforce capable of responding effectively to disasters

The Impact and Interactions of Race and Gender on Healthcare Use and Spending Irritable Bowel Syndrome

Studies examining the effects of social determinants of health on healthcare use in irritable bowel syndrome (IBS) are scarce. We aimed to assess healthcare spending among different racial/ethnic groups and genders in adults with IBS. We performed a retrospective cohort analysis of adults diagnosed with IBS between 2016-2021 using Optum's de-identified Clinformatics® Data Mart Database . We analyzed total annual and IBS-specific costs, utilization and costs of individual services, and prescriptions. We compared outcomes across racial/ethnic groups and by gender after adjusting for covariates and examined race-gender interactions. Among 95,319 adults with IBS, healthcare spending varied significantly by race and gender. Total all-cause and IBS-specific costs were lower in men than in women and in Asian and Hispanic patients than in White patients. Compared to White patients, Black patients had higher total IBS-specific costs, all-cause prescriptions costs, IBS-related radiology and laboratory costs, and emergency department (ED) care whileAsian and Hispanic patients incurred lower costs for ED care, hospitalizations, and all-cause prescriptions. Endoscopy costs were lower in racial minority groups. Women had higher spending for most services compared to men, but gender differences in most IBS-related services were small. All-cause hospitalization and endoscopy costs were higher in men, but IBS-specific hospitalization and endoscopy costs were higher in women. Gender disparities in all-cause individual services also varied by race. Overall and IBS-related spending is higher in women, but gender differences in IBS-related care are small. Racial/ethnic comparisons show reduced spending in Asian and Hispanic patients, increased ED care in Black patients, and variations in spending patterns. Gender disparities differ by race.

Cannabinoid hyperemesis syndrome-an emerging gastrointestinal disorder and clinical challenge

Nausea and vomiting are not uncommon symptoms resulting in emergency department (ED) or primary care visits. One of the emerging etiologies – Cannabinoid Hyperemesis Syndrome (CHS) remains significantly under-diagnosed, often resulting in unnecessary repeat ED visits and testing. This is in part due to lack of experience with and knowledge about CHS by health care professionals. Characterized by cyclic vomiting, often severe and intractable, it is frequently associated with a form of self-treatment; the compulsive need to take hot showers, and in the context of chronic cannabis use. With increased legalization and resultant accessibility to cannabis containing products, the risk of adverse events is significantly rising. Lack of clinical familiarity with the range of potential deleterious physical and mental health effects associated with cannabis leads to delays in appropriate diagnosis and effective treatment of CHS. Moreover, commonly utilized anti-emetics, such as ondansetron, and similar 5 HT drugs may not fully attenuate symptoms of CHS, and other interventions may be necessary; ultimately abstinence being the most effective long term clinical preventive approach. The objective of this review article is to assist the clinician in identifying the specific clinical characteristics of CHS, distinguishing it from other causes of CVS or nausea and vomiting, to facilitate more rapid, effective interventions. Collaboration with substance use professionals should also be considered during CHS treatment.

"What Matters" in the Emergency Department: A Prospective Analysis of Older Adults' Concerns and Desired Outcomes.

To describe "What Matters" to older adults seeking emergency department (ED) care and to identify patient characteristics associated with meeting desired outcomes. As part of the 4Ms framework, identifying "What Matters" has been captured across healthcare settings, yet limited attention has been directed to older adults in the ED. We performed a secondary analysis of a multicenter prospective observational study. The study enrolled 1013 patients aged 65 and older during an ED encounter and performed 90-day follow-up interviews. The primary outcome was the quantification of "What Matters" (concerns and desired outcomes) to older adults during emergency care. As secondary outcomes, we assessed concerns at day 90, if desired outcomes were met at follow-up, and patient characteristics associated with outcome achievement by estimating multivariable logistic regression models. Older adults reported specific concerns at the time of the ED visit including: (1) symptom identification and/or persistence (31.4%), (2) ability to take care of oneself (19.4%), and (3) end-of-life (17.8%). Desired outcomes expressed by participants included: (1) getting well and symptom resolution (72.0%), (2) obtaining a diagnosis (25.7%), and (3) functional independence (19.5%). At day 90 follow-up, concerns remained similar to the initial ED visit, and the majority of participants (66.2%) achieved their desired outcome. Frailty (adjusted odds ratio = 0.56, 95% CI: 0.38-0.83, P < 0.01) was associated with older adults not meeting their desired outcomes. Older adults identified a variety of concerns during emergency care, and two-thirds reported that desired outcomes were met at longitudinal day 90 follow-up.

Prospective Survey of Discrimination in Pregnant Persons and Correlation with Unplanned Healthcare Utilization.

To determine the association between lifetime exposure to discrimination and unplanned healthcare utilization in pregnant persons. This was a prospective cohort study of pregnant persons receiving care from 2021 to 2022. Primary data was collected from participants on sociodemographic factors and on Perceived Ethnic Discrimination Questionnaire (PED-Q), a validated 17-item scale measuring perceived lifetime interpersonal racial and ethnic discrimination in four domains: work/school, social exclusion, stigmatization, and threat. The primary outcome was unplanned healthcare utilization, defined as unplanned labor and delivery admissions, triage, Emergency Department, or urgent care visits. Bivariate and multivariate analyses were done to examine the association between lifetime exposure to discrimination and unplanned healthcare utilization. A total of 289 completed the PED-Q and were included in the analysis. Of these, 123 (42.6%) had unplanned healthcare utilization. Mean (SD) of lifetime racial and ethnic discrimination was significantly higher in people with unplanned healthcare utilization compared to those with planned healthcare utilization [1.67 (0.63) vs 1.48 (0.45), p = 0.003]. Univariate analysis showed that lifetime racial and ethnic discrimination was significantly associated with unplanned healthcare utilization (OR1.96, 95% CI 0.23-3.11). Significant associations were found between unplanned healthcare utilization and maternal age (p = 0.04), insurance type (p = 0.01), married status (p < 0.001), education (p = 0.013), household income (p = 0.001), and chronic hypertension (p = 0.004). After controlling for potential confounding factors, self-reported lifetime racial and ethnic discrimination remained significantly associated with higher odds of unplanned healthcare utilization (aOR 1.78, CI 95% 1.01-3.11). We found that a higher level of self-reported lifetime racial and ethnic discrimination was associated with increased unplanned healthcare utilization during pregnancy.

Provision of Adolescent Confidential Care in a Pediatric Tertiary Care Hospital

PurposeAdolescents are more likely to disclose sensitive health information if confidentiality is assured. We sought to evaluate the frequency, quality, and factors associated with provision of confidential care to adolescent patients at a pediatric teaching hospital. MethodsWe undertook a cross-sectional survey of adolescents presenting to a tertiary pediatric hospital from January 2019 to January 2020. A convenience sample of adolescents eligible for confidential care under Quebec legislation (aged 14–18 years) were surveyed either following their emergency department (ED) or inpatient care. Participants completed a self-administered electronic questionnaire regarding the confidential care provided at their initial ED or inpatient medical encounter. Multivariable logistic regression was used to identify factors associated with the provision of confidential care. ResultsOverall, 406 adolescents completed the survey (335 ED; 71 inpatient); 137 (33.7%) endorsed being offered and 95 (69%) accepted confidential time. Among adolescents receiving confidential care, 43% reported that the limits of confidentiality were reviewed and 23% reported that private issues were still discussed in front of family members. Multivariable analysis revealed inpatient setting (adjusted odds ratio [aOR] 2.28, 1.04–5.01), female gender (aOR 2.02, 1.21–3.38), age (aOR 1.67, 1.03–2.69), psychiatric diagnosis (aOR 8.10, 1.47–44.6), resident involvement (aOR 1.96, I.09–3.53) were all positively associated with the provision of confidential care. DiscussionSurvey results suggest inadequate provision of confidential care in an academic pediatric hospital. The limits of confidentiality were not consistently explained, and breaches in confidentiality were not infrequent. Confidentiality-specific education initiatives are necessary to improve the frequency and quality of confidential care for adolescents in tertiary care settings.

Abstract 4135726: Prospective validation and implementation pilot study of an emergency department heart failure risk stratification tool: STRIDE-HF

Background: We previously found the STRIDE-HF emergency department (ED) risk tool accurately predicted risk of a 30-day serious adverse event (SAE), including 30-day mortality, cardiopulmonary resuscitation, intra-aortic balloon pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Research question: We sought to prospectively validate STRIDE-HF and describe safety of the deployed model in a clinical pilot. We hypothesized that performance would decrease slightly with prospective evaluation and that real-time risk display would contribute to safe disposition decisions. Goals: 1) To prospectively validate KPCARES-HF across 21 community EDs among ED patients with acute heart failure (AHF) from January 1, 2023 – December 31 st , 2023; and 2) to describe outcomes among patients predicted to be very low risk and discharged home in the clinical pilot. Methods: For prospective validation, we report 30-day mortality rates by risk strata. We assess model performance using area under the receiver operator curve (AUROC) and sensitivity at a key clinical threshold. We describe rates of 30-day SAE among patients predicted to be very low risk and discharged after ED or observation unit care in the clinical pilot. Results: There were 13,274 ED patients in the prospective validation; median age was 76, 50.8% were female, and 44.5% were non-White. We found 11.4%, 24.8%, 31.9%, and 31.9% of patients were very low, low, moderate, and high risk, respectively, while 21.6%, 15.2% and 63.0% were discharged, observed, and admitted, respectively. Among discharged patients, 29.2% and 13.3% were moderate or high risk, respectively, and 30-day mortality rates among these patients were 2.2% and 8.4%, respectively. Among 8,363 admitted patients, 27.7% were very low or low risk. Conclusions: STRIDE-HF maintained high predictive accuracy with prospective validation in this diverse, multi-center cohort. Our findings suggest that use of STRIDE-HF might help better align risk with admission decision and can be safely used to assist providers in identifying patients who may be stable for outpatient care.

Identifying the Needs of Paediatric-Friendly Care in Emergency Department: A Delphi Study.

To systematically analyse expert perspectives on paediatric-friendly care in the emergency department and establish specific indicators. With an increasing number of children seeking emergency care, nurses must understand the specific needs of paediatric patients and their families. A two-round modified Delphi method was used in this study. In this study, experts from clinical practice and academia assessed 56 paediatric-friendly care criteria in the emergency department. Data were collected to establish a consensus and ensure content validity. Thirty experts completed two survey rounds with response rates of 100% and 93.3%, respectively. In the initial survey, no consensus was reached for eight items. After the items were consolidated, 37 paediatric emergency-friendly care needs were identified. For each need, the item-level content validity index exceeded 0.79 for importance and feasibility. The average scale-level content validity index values were 0.95 and 0.92 for importance and feasibility. These needs were categorised into six dimensions: timely comfort (3 items), emotional care (5 items), frontline safety (11 items), emergency response (10 items), human resources support (5 items) and treatment efficiency (3 items). Paediatric emergency nurses play a vital role in caring for children, improving soft skills through compassion and training and ensuring a well-equipped, safe environment in the emergency department. This study offers valuable insights for emergency department nurses on the needs of children and their families, emphasising the importance of patient and family education, environmental considerations and the role of certified child life specialists in supporting the emergency healthcare team and ensuring appropriate paediatric care. No direct patient, service user, caregiver or public involvement existed in this study.

Respiratory Viral Co-infection in SARS-CoV-2-Infected Children During the Early and Late Pandemic Periods

Background: Knowledge regarding the impact of respiratory pathogen co-infection in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children seeking emergency department care is limited, specifically as it relates to the association between SARS-CoV-2 viral co-infection and disease severity and factors associated with co-infection. Methods: This secondary analysis included data from 2 prospective cohort studies conducted between March 2020 and February 2022 that included children &lt;18 years of age tested for SARS-CoV-2 infection along with additional respiratory viruses in a participating emergency department. Outcomes included the detection rate of other respiratory viruses and the occurrence of severe outcomes (ie, intensive interventions, severe organ impairment and death). Results: We included 2520 participants, of whom 388 (15.4%) were SARS-CoV-2-positive. Detection of additional respiratory viruses occurred in 18.3% (71/388) of SARS-CoV-2-positive children, with rhinovirus/enterovirus being most frequently detected (42/388; 10.8%). In multivariable analyses (adjusted odds ratio and 95% confidence interval), among SARS-CoV-2-positive children, detection of another respiratory virus was not associated with severe outcomes [1.74 (0.80–3.79)], but detection of rhinovirus/enterovirus [vs. isolated SARS-CoV-2 detection 3.56 (1.49–8.51)] and having any preexisting chronic medical condition [2.15 (1.06–4.36)] were associated with severe outcomes. Among SARS-CoV-2-positive children, characteristics independently associated with an increased odds of any other viral co-infection included: age and delta variant infection. Conclusions: Approximately 1 in 5 children infected with SARS-CoV-2 had co-infection with another respiratory virus, and co-infection with rhinovirus/enterovirus was associated with severe outcomes. When public health restrictions were relaxed, co-infections increased.

Postpartum Acute Care Utilization in a Health Care System in the Southeastern United States.

Introduction: Postpartum acute care utilization (PACU), including visits to an emergency department, obstetric triage, or urgent care ("outpatient"), and hospital readmissions, may indicate medical complications and signal unmet health needs. Methods: We estimated the incidence of PACU and examined patterns by sociodemographic factors, pregnancy and birth characteristics, time since discharge from the birth hospitalization, and medical indications. We constructed a retrospective cohort of people aged ≥18 years who delivered ≥1 liveborn infant >20 weeks of gestation from July 1, 2021, to December 31, 2022, using electronic health record data from a quaternary maternity hospital in the Southeastern United States PACU data throughout the health care system were collected through March 31, 2023. We excluded people with a hospital stay >6 days (n = 29). Results: In this cohort of 6,041 birthing people, 11.3% had ≥1 outpatient encounters(range 0-6) and 3.2% had ≥1 hospital readmissions (range 0-4) within 12 weeks of discharge from the birth hospitalization. Median time to first outpatient PACU was 10 days post-discharge and 6 days for first hospital readmission. Among encounters for the top five medical indications, time to first postpartum acute care encounter varied by medical indication (log-rank test of equality over strata Chi-square = 69.93, degrees of freedom = 4, p < 0.0001). Complications specified during the puerperium (n = 234) and hypertension and hypertensive-related conditions complicating the puerperium (n = 87) were the two most frequent indications. Conclusion: These findings can inform efforts to direct health resources to improve postpartum health care and health outcomes.

Why Veterans Choose VA Versus non-VA Emergency Care: A Qualitative Study.

In ensuring the timely delivery of emergency care to Veterans, Veterans Affairs (VA) offers both emergency care services in its own facilities and, increasingly, purchases care for Veterans in non-VA (community) emergency department (ED) settings. Although in recent years emergency care coverage has become the single largest contributor to VA community care spending, no study to date has examined Veteran decision-making as it relates to ED setting choice. The purpose of this study is to identify and describe reasons why Veterans choose VA versus non-VA emergency care settings. Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured telephone interviews from December 2018 through March 2020 with 50 Veterans to understand the factors Veterans consider when deciding where to obtain ED care. Interviews were audio-recorded and transcribed verbatim. We conducted a directed content analysis of interview transcripts and developed a matrix to summarize and categorize each Veteran's decision-making process to compare participants and to identify common patterns. When choosing between VA and non-VA-EDs, Veterans described 3 distinct patterns of decision-making: (1) choosing the closest ED (often community) for acute conditions; (2) traveling farther for VA care due to preference and financial coverage; and (3) selecting VA when both types of ED care were equidistant. Perceptions of community resources, condition-specific needs, financial considerations, and personal preferences dominated the decision-making. For example, most Veterans (74%) rated their acuity as high, and self-perceived severity/urgency of their condition was the most cited factor influencing where Veterans decided to go for ED care. Our qualitative results help provide insight into how and why Veterans choose to seek emergency care. As the number of Veterans treated in non-VA EDs continues to rise, VA and non-VA ED providers as well as policy makers may benefit from understanding the challenges Veterans face when making this decision.

Long-term clinical outcomes and healthcare resource utilization in male and female patients following hospitalization for heart failure.

Heart failure (HF) is a leading cause of hospitalization, and sex differences in care have been described. We assessed sex-specific clinical outcomes and healthcare resource utilization following hospitalization for HF. This was an exploratory analysis of patients hospitalized for HF across 10 Canadian hospitals in the Patient-Centered Care Transitions in HF (PACT-HF) cluster-randomized trial. The primary outcome was all-cause mortality. Secondary outcomes included all-cause readmissions, HF readmissions, emergency department (ED) visits, and healthcare resource utilization. Outcomes were obtained via linkages with administrative datasets. Among 4441 patients discharged alive, 50.7% were female. By 5 years, 63.6% and 65.5% of male and female patients, respectively, had died (p = 0.19); 85.4% and 84.4%, respectively, were readmitted (p = 0.35); and 72.2% and 70.9%, respectively, received ED care without hospitalization (p = 0.34). There were no sex differences in mean [SD] number of all-cause readmissions (males, 2.8 [7.8] and females, 3.0 [8.4], p = 0.54), HF readmissions (males, 0.9 [3.6] and females, 0.9 [4.5], p = 0.80), or ED visits (males, 1.8 [11.3] and females, 1.5 [6.0], p = 0.24) per person. There were no sex differences in mean [SD] annual direct healthcare cost per patient (males, $80 334 [116 762] versus females, $81 010 [112 625], p = 0.90), but males received more specialist, multidisciplinary HF clinic, haemodialysis, and day surgical care, and females received more home visits, continuing/convalescent care, and long-term care. Annualized clinical events were highest in first year following index discharge in both males and females. Among people discharged alive after hospitalization for HF, there were no sex differences in total and annual deaths, readmissions, and ED visits, or in total direct healthcare costs. Despite similar risk profiles, males received relatively more specialist care and day surgical procedures, and females received more supportive care. ClinicalTrials.gov NCT02112227.

Effectiveness of BNT162b2 XBB vaccine in the US Veterans Affairs Healthcare System

Data evaluating effectiveness of XBB.1.5-adapted vaccines against JN.1-related endpoints are scarce. This nationwide test-negative case-control study within the US Veterans Affairs Healthcare System aims to estimate vaccine effectiveness (VE) of BNT162b2 XBB.1.5-adapted vaccine compared to not receiving an XBB vaccine of any kind against COVID-19 hospitalization, emergency department or urgent care visits (ED/UC), and outpatient visits. Between September 25, 2023 and January 31, 2024, effectiveness was 24–35% during a period of JN.1 predominance and 50–61% during XBB predominance across all outcomes. VE within 60 days of vaccination during the likely JN.1 period was 32% (95% confidence interval 3–52%) against hospitalization, 41% (23–54%) against ED/UC visits, and 31% (1–52%) against outpatient visits. Corresponding VE during the likely XBB period was 62% (44–74%), 52% (37–63%), and 50% (25–66%) by setting, respectively. Here, we show the importance of strain match to maximize the public health impact of COVID-19 vaccination.

Barriers and enablers to nurse-initiated care in emergency departments: An embedded mixed methods survey study

BackgroundIncreased demand, wait times and length of stay have seen many emergency departments implement nurse-initiated protocols In New South Wales, Australia, 74 nurse-initiated protocols have been developed for implementation. The aim of this paper is to identify the barriers and enablers to nurses’ use of these protocols to inform and maximise future implementation. MethodsData were collected via surveys informed by the theoretical domains' framework and the Practice Environment Scale of the Nursing Work Index (PES-NWI). Descriptive statistics summarised quantitative data and content analysis was performed on qualitative data. Results were integrated and classified as barriers or enablers to nurses’ use of protocols. ResultsThe nurses’ response rate was 82 % (n = 76) and doctors 72 % (n = 34) Six categories were generated; one barrier (lack of resources), three enablers (patient and organisational benefits, nurses’ motivation, nurses’ desire to develop their practice) and two were both a barrier and enabler ( nurse confidence and the work environment). ConclusionEmergency nurses are highly motivated to use nurse-initiated protocols to positively impact patient outcomes. However, a lack of resources, time, access to education and confidence are barriers to use that need to be addressed when designing implementation.

Incidental Detection of Previously Unknown Strokes on Head CT Examinations: An Untapped Opportunity for Secondary Prevention

BackgroundThe incidental discovery of previously unknown strokes on neuroimaging is an opportunity to implement secondary prevention, reducing the risk of recurrent strokes by up to 80%. ObjectiveTo evaluate the prevalence of previously unknown strokes on emergency department (ED) head CT imaging and identify associated patient and imaging factors. MethodsRetrospective study of adult patients receiving head CT (age ≥ 18 years) at 3 EDs between July and December 2023. Old strokes on CT imaging were categorized as previously known or unknown. Patient and imaging factors associated with unknown strokes were assessed via univariable regression, multivariable regression, and decision tree analysis. ResultsIn 21,985 ED encounters with head CT, 869 (4.0%) examinations demonstrated an old stroke (mean age, 74.4 years ± 14.0 [SD]), of which 372 (43%; 1.7% of all CTs) were unknown. Univariable analysis showed that unknown strokes were associated with greater age (OR, 1.03; 95% CI: 1.02-1.04; P < 0.001), a single site of old stroke (OR, 2.7; 95% CI: 2.06-3.58; P < 0.001), smaller strokes (OR, 1.8, 95% CI: 1.6-2.0, P <0.001) as well as gangliocapsular (OR, 2.8; 95% CI: 1.9-4.0; P < 0.001) and cerebellar location (OR, 2.1; 95% CI: 1.4-3.2; P < 0.001). Results of further analyses corroborated those of the univariable regression. ConclusionMore than a third of old strokes on head CT imaging are unknown to patients and clinicians. Capturing this opportunity for secondary prevention could benefit 100,000-200,000 patients per year in the US, based on trends in ED care.

Nexus of Quality Use of Medicines, Pharmacists' Activities, and the Emergency Department: A Narrative Review.

Acute care provided in the hospital's emergency department (ED) is a key component of the healthcare system that serves as an essential bridge between outpatient and inpatient care. However, due to the emergency-driven nature of presenting problems and the urgency of care required, the ED is more prone to unintended medication regimen changes than other departments. Ensuring quality use of medicines (QUM), defined as "choosing suitable medicines and using them safely and effectively", remains a challenge in the ED and hence requires special attention. The role of pharmacists in the ED has evolved considerably, transitioning from traditional inventory management to delivering comprehensive clinical pharmacy services, such as medication reconciliation and review. Emerging roles for ED pharmacists now include medication charting and prescribing and active participation in resuscitation efforts. Additionally, ED pharmacists are involved in research and educational initiatives. However, the ED setting is still facing heightened service demands in terms of the number of patients presenting to EDs and longer ED stays. Addressing these challenges necessitates innovation and reform in ED care to effectively manage the complex, rising demand for ED care and to meet government-imposed service quality indicators. An example is redesigning the medication use process, which could necessitate a shift in skill mix or an expansion of the roles of ED pharmacists, particularly in areas such as medication charting and prescribing. Collaborative efforts between pharmacists and physicians have demonstrated positive outcomes and should thus be adopted as the standard practice in improving the quality use of medicines in the ED.