Community-based Emergency Department Research Articles

Nonfatal Strangulation Injuries: Improving Physician Knowledge and Attitudes

In the emergency department, physicians evaluate patients who have experienced nonfatal strangulation resulting from sexual assault or intimate partner violence. Given the prevalence and potential consequences of nonfatal strangulation injuries, physicians need confidence in their decision-making for these patients. Previous educational interventions effectively improved physician knowledge of sexual assault and intimate partner violence patients; however, no studies have been conducted with the goal of improving physician knowledge about nonfatal strangulation injuries in this population. Pre- and post-intervention surveys were administered to physicians from four different south-central Indiana emergency departments. These surveys assessed comfort and knowledge regarding the treatment of survivors of sexual assault, intimate partner violence, and nonfatal strangulation. Additionally, six vignette-style questions designed to evaluate knowledge in clinical scenarios were also administered. A 15-min, interactive, educational presentation was delivered prior to the post-survey. Post-intervention participants tended to rate awareness of imaging recommendations and resources, decision-making, history taking, and use of trauma-informed care higher than pre-intervention participants. The post-intervention group ( n = 12) answered more clinical vignette questions correctly with an average of 92% correct compared with the pre-intervention group ( n = 22), which had an average of 76% correct. Based on these results a 15-min educational intervention was effective in improving physician knowledge, confidence, and comfort in treating patients who have experienced nonfatal strangulation in small community-based emergency department settings. In the future, similar interventions may be implemented in other emergency departments to increase awareness about the evaluation and treatment of nonfatal strangulation injuries.

Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates.

More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency. This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email. A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001). This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

How Did That Get There? A Case Series of Adolescent Foreign Bodies.

Pediatric foreign bodies (FBs) come in many shapes and sizes, and the method by which they enter the body can greatly impact the level of acuity at presentation. Most FBs in children are found in those younger than 5 years old, but the following 3 cases were found in adolescent patients. We report on 3 adolescent patients who presented to a single community-based emergency department with the chief complaint of abdominal pain and were found to have complications of abdominal FBs. If undiagnosed, the initial indolent courses of FBs can lead to serious complications, as shown in these examples. These cases emphasize the need for physicians to maintain a high level of suspicion, to perform detailed histories, and to consider advanced imaging despite reassuring vital signs or physical examination.

Abstract TP58: Dedicated Stroke Emergency Department APP/Physician Team Improves Door To Provider Times In A Comprehensive Stroke Center

Background: Stroke is the leading cause of disability in the US, yet best standard practices for acute stroke care even among premier hospitals in the US varies. The AHA/ASA Get with the Guidelines (GWTG) program set out to create standard metrics to reduce this variation between hospitals. One such measure is the Door to Provider time, with a goal of 10 minutes or less. This goal can be difficult to achieve in large, high volume, Emergency Departments with multiple providers present at a given time. Specialized care has been shown to improve patient outcomes. We set out to create a simple yet effective process improvement of creating a dedicated ED APP/Physician team for each shift to achieve this goal. Methods: Starting in January 2020, a NIHSS trained APP was dedicated to provide assessments of all potential stroke patients upon arrival to the emergency department for a particular shift with a supervising attending ED physician, who also provided backup in situations of concurrent cases. The APP was assigned a phone each shift that can be notified by medical control for any EMS pre arrival stroke notifications and by the triage clinician for ambulatory arrivals. Data was collected starting on January 15 th 2020 for each “Stroke Alert” page and the Door to Provider time was calculated based on documentation in the Emergency Department timeline. From January 15 th 2020 to March 31 st 2022, 2,410 patients were evaluated. Results: The Door to Provider time goal was met greater than 80% of the time. Conclusion: Phase III of Target: Stroke sets challenging time goals for the prompt evaluation and treatment of patients with acute ischemic stroke with an ultimate objective of improved patient outcomes. Through the simple implementation of a dedicated NIHSS trained ED APP and Physician provider for each shift in our high volume, community based Emergency department, we were able to improve and sustain our door to provider times. These process improvement outcomes persisted through the COVID 19 pandemic!

Describing Nonfatal Intimate Partner Strangulation Presentation and Evaluation in a Community-Based Hospital: Partnerships Between the Emergency Department and In-House Advocates.

To describe characteristics of strangulation, and associated medical care, documentation, and injuries of women after nonfatal intimate partner strangulation (NF-IPS) who present for care to a community-based emergency department (ED) with an associated intimate partner violence (IPV) advocacy program between 2008 and 2016. A retrospective review of 345 female ED patients' medical records who sought care at a community hospital ED following a physical assault including strangulation by an intimate partner was conducted. Demographics, characteristics related to reported signs and symptoms, injuries, and subsequent imaging, diagnoses, and discharge information were abstracted. Commonly reported symptoms were neck pain (67.2%) and headache (45.8%), with fewer patients reporting more severe symptoms such as loss of consciousness (22.6%), dysphagia (25.0%), or dysphonia (26.7%). Rates of patients disclosing strangulation to the entire multidisciplinary team and dedicated neck imaging appeared to improve between 2008 and 2014. Among the 45 patients with noted head and neck findings, 2 patients were found to have an internal carotid artery dissection, 2 patients were found to have strokes, and 1 patient was found to have an intracranial hemorrhage. Survivors of NF-IPS may present to community-based hospitals, and existing imaging guidelines can support clinicians in identifying serious internal injury such as carotid artery dissection and stroke. Further research is needed to better discern symptoms previously attributed to psychological trauma from poststrangulation brain injury. This study contributes to the growing literature on NF-IPS with data specific to community-based ED visits.

1357. Patterns of Extragenital Gonorrhea and Chlamydia Testing at a Community-Based Academic Emergency Department in Columbus, Ohio

BackgroundSexually transmitted infections (STI), including gonorrhea (GC) and chlamydia (CT), are on the rise in the U.S. and emergency department (ED) visits for STI-related complaints are common. The ED plays a key role in testing for GC/CT. In addition to testing genital sites for GC/CT, the Centers for Disease Control and Prevention (CDC) recommends extragenital testing (oral/rectal) based on sexual history and exposure. In this study, we reviewed the proportion of extragenital GC/CT tests performed at a community-based academic ED in Columbus, Ohio.MethodsThis study was a retrospective chart review of all GC/CT tests performed at the Ohio State University Hospitals East ED from November 1, 2018 to November 1, 2020. Clinical and demographic information was collected for all patients who received extragenital GC/CT testing, including symptoms, test results, and documentation of sexual practices. A random convenience sample of 100 patients who only had genital GC/CT testing performed was also reviewed.ResultsOf the 5644 GC/CT tests performed during the study period, only 364 (6.4%) were from extragenital sites, which included 311 (5.5%) from oral and 53 (< 1%) from rectal sites. Of the 100 patients reviewed who did not have extragenital GC/CT testing performed, only 5 (5%) had documentation of sexual practices, compared with 177/311 (56.9%) of those who had oral testing and 27/31 (50.94%) who had rectal testing performed. In the cohort of 100 patients who did not receive extra genital testing 28% were male and average age was 29. In the group who received extragenital testing 40% were male and average age was 30. The most common complaint across all groups was genital dischargeConclusionDespite the substantial number of CG/CT tests performed in the ED, only a very small proportion were from extragenital sites. Interventions are needed to identify and overcome barriers to extragenital GC/CT testing in the ED.Disclosures Mohammad Mahdee Sobhanie, M.D., Regeneron (Scientific Research Study Investigator)Regeneron (Scientific Research Study Investigator, Was a sub-investigator for Regeneron 2066 and 2069) Carlos Malvestutto, M.D., Lilly (Scientific Research Study Investigator)Regeneron Inc. (Scientific Research Study Investigator)ViiV Healthcare (Advisor or Review Panel member)

Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners.

Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.

A Guide for Medical Educators: How to Design and Implement In Situ Simulation in an Academic Emergency Department to Support Interprofessional Education.

In situ simulation (ISS) put simulation training directly into the clinical practice environment. Although ISS creates opportunities to identify latent system threats, understand culture, and improve team dynamics, there are limited resources for medical educators to guide the development and implementation of ISS at academic (or community-based) emergency departments (EDs). We describe the implementation of ISS in a high-volume urban ED to help educators understand the requirements and limitations of successful program design. During an academic year, 66 individual learners participated in at least one of our 22 training sessions, a cohort that included 37 nurses, 17 physicians, eight physician assistants, and four allied health professionals. Feedback from these participants and case facilitators informed our iterative process of review and development of program guidelines and best practices. We share these key technical points and the themes we found to be essential to the successful implementation of an ISS program: consideration of session timing, participant buy-in, flexibility, and threats to professional identity. Overall, our report demonstrates the feasibility of implementing an ISS program in a high-volume urban ED and provides medical educators with a guide for creating an ISS program for interprofessional education.

Development and Validation of Machine Learning Models to Predict Admission From Emergency Department to Inpatient and Intensive Care Units

This study aimed to develop and validate 2 machine learning models that use historical and current-visit patient data from electronic health records to predict the probability of patient admission to either an inpatient unit or ICU at each hour (up to 24 hours) of an emergency department (ED) encounter. The secondary goal was to provide a framework for the operational implementation of these machine learning models. Data were curated from 468,167 adult patient encounters in 3 EDs (1 academic and 2 community-based EDs) of a large academic health system from August 1, 2015, to October 31, 2018. The models were validated using encounter data from January 1, 2019, to December 31, 2019. An operational user dashboard was developed, and the models were run on real-time encounter data. For the intermediate admission model, the area under the receiver operating characteristic curve was 0.873 and the area under the precision-recall curve was 0.636. For the ICU admission model, the area under the receiver operating characteristic curve was 0.951 and the area under the precision-recall curve was 0.461. The models had similar performance in both the academic- and community-based settings as well as across the 2019 and real-time encounter data. Machine learning models were developed to accurately make predictions regarding the probability of inpatient or ICU admission throughout the entire duration of a patient's encounter in ED and not just at the time of triage. These models remained accurate for a patient cohort beyond the time period of the initial training data and were integrated to run on live electronic health record data, with similar performance.

The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias.

INTRODUCTIONTraditional evaluation for suspicion of gallstone or gallbladder-related disease includes evaluation with a formal technician-performed ultrasound. However, the use of point-of-care bedside ultrasounds (Bedside US) has been shown to be a viable alternative for the diagnosis of gallstones and gallbladder-related diseases. Purpose Statement: The purpose of this study was to evaluate the impact of Bedside US use in gallbladder evaluation on key patient care outcomes within our community-based emergency department setting.METHODSThis retrospective study compared the use of no ultrasound (No US), a formal technician performed ultrasound (Tech US) and Bedside US for gallstone and gallbladder related diseases within a community hospital emergency department between January 1, 2015 and January 1, 2018. Initial vitals, lab work, patient socio-demographics, medical history, emergency department length of stay in hours and disposition were reviewed.RESULTSOf a total N = 449 patients included, patients who received a Bedside US had the fewest computerized tomography scans (No US 62% vs. Tech US 29% vs. Bedside US 16%; p < 0.0001), the shortest median emergency department length of stay (No US 4.5 days vs. Tech US 5.0 days vs. Bedside US 3.0 days; p < 0.0001), and were more likely to be discharged home (No US 41% vs. Tech US 55% vs. Bedside US 81%; p = 0.0006) compared to those that received no ultrasound or a formal ultrasound. Patients who received a Bedside US also had the statistically significant highest incidence of prior cholelithiasis (No US 29.4% vs Tech US 14.3% vs. Bedside US 31.3%; p = 0.001) and lowest total median bilirubin levels (No US 0.5 vs. Tech US 0.5 vs. Bedside US 0.3; p = 0.016) when compared to the other two groups.CONCLUSIONSAlthough there was a confirmation bias, these study results indicate that point-of-care bedside ultrasound could be a viable alternative for gallstones and gallbladder-related diseases with benefits of use in a community hospital setting.

In Situ Simulation to Promote Residents as Resuscitation Leaders.

Objectives Our study sought to assess whether perceptions of residents as resuscitation team leaders could be improved by using emergency department (ED) in situ simulations involving ED staff. Secondarily, we monitored changes indicated in overall resuscitation team dynamics.MethodsWe conducted a prospective experimental study over the 2018-2019 academic year. Data were collected at a community-based ED with an emergency medicine residency program. Prior to starting the education, all ED staff including residents, attending physicians nurses and techs completed a survey of their perceptions of team performance and leadership during medical resuscitations. Throughout the year, residents and ED staff members were exposed to various in situ simulation scenarios. A follow-up survey was administered to reassess resident and ED staff perceptions of team dynamics and, specifically, residents as patient care team leaders. A relational coordination survey analysis was performed, dichotomized by professional domain.ResultsA total of 20 participants completed surveys before and after the in situ simulations, covering the professional domains with matched pre-simulation and post-simulation data showing significant improvement in communication and team dynamics for residents (p = 0.029) and other ED staff in medical resuscitations. Using residents as the team leaders for the simulation improved perceived leadership during resuscitation (p = 0.006).ConclusionsOur study suggests that in situ simulation within the ED leads to improved team dynamics and defined roles while emphasizing the resident as a resuscitation leader.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Mycoplasma genitalium Infection in Young Women Without Urogenital Symptoms Presenting to a Community-Based Emergency Department in Birmingham, Alabama.

We used the Food and Drug Administration-cleared Aptima Mycoplasma genitalium assay to evaluate for M. genitalium infection among young women without urogenital symptoms presenting to a community-based emergency department in Birmingham, Alabama, between August 2016 to August 2019 for evaluation of nongynecological concerns. M. genitalium was detected in 23 (14.8%) of 155 women.

1623. Implementation of Electronic Readmission Alert for Discharged Patients Reduces Risk of Secondary Measles Exposure Events

BackgroundMeasles is a highly infectious illness that is causing increased numbers of outbreaks in the United States. Patients involved in a healthcare measles exposure and who have been discharged before identification of exposure are at risk of becoming infectious in the community, and may seek healthcare within their infectious window, creating a secondary exposure risk for healthcare systems. A measles exposure in an integrated healthcare system occurred, resulting in patient exposures in multiple locations at three campuses, including two community-based emergency departments and three inpatient units. There were 159 patients who were included in the exposure group; 123 were exposed in an ED, and 36 were exposed in an inpatient setting. Ninety-four percent (149/159) of the patients had been discharged at the time of measles case identification and were in the pre-infectious phase of illness. Of those, 36 percent (54/149) presented back to the healthcare system within the potentially infectious window; these 54 patients had 97 individual healthcare contacts in the potentially infectious period following the exposure event. Sixty-one of the 97 return visits (63%) were within the window in which the exposed patients were potentially infectious. Return locations included the three exposure facilities and inpatient and outpatient locations at 10 other system campuses.MethodsAn alert system was developed within the electronic medical record that identified patients that were involved in the exposure, and guided clinicians to mask and place in airborne isolation until measles immunity was verified.ResultsThe alert activated 13 days after the exposure was identified, and identified 100% of returns to healthcare at all sites within the system, representing 48% of all potential secondary exposure events (29 /61). No secondary exposures or transmission occurred.ConclusionMeasles exposures are an enormous burden on healthcare organizations and public health systems. When exposures occur, healthcare organizations need systems to rapidly identify discharged patients who may return within the potentially infectious window. Rapid development of electronic readmission alerts can help standardize identification and reduce the risk of subsequent exposure.Disclosures All authors: No reported disclosures.

416. Improvement in Syphilis and HIV Screening Rates at a Community-Based Emergency Department in Columbus, Ohio: Six Month Post-Intervention Analysis

BackgroundSexually transmitted infections (STIs) disproportionally affect individuals living in underserved areas and Emergency Departments (ED) can play a major role in STI screening. Given the overlapping risk factors for STIs, patients screened for gonorrhea and chlamydia should also be screened for syphilis and HIV. Rates of syphilis/HIV screening in the ED are very low and barriers include lack of knowledge about the risk/prevalence, difficulty with results interpretation, and concerns about follow-up.MethodsThe main study objective was to improve rates of syphilis/HIV screening in a community-based ED in Columbus, OH. A team of clinical providers, case managers, and social workers was formed to address barriers to screening. Using root cause analysis and data feedback, a multistep intervention that included provider education along with expert review of syphilis/HIV results was implemented to ensure proper screening, treatment and rapid linkage to care. Syphilis/HIV screening rates in the ED were compared between two periods: 2012–2017 (pre-intervention) and November 2018–April 2019 (post-intervention).ResultsBetween 2012 and 2017, there were 24,427 ED encounters where any STI test was ordered. There were 23,652 (97%) tests for chlamydia, 23,637 (97%) for gonorrhea, 254 (1%) for syphilis, and 466 (2%) for HIV. Twenty-four (0.1%) encounters had screening that included all four tests. Six months after starting the intervention, there were 1,590 encounters where any STI test was ordered. There were 1,444 (91%) tests for chlamydia, 1,446 (91%) for gonorrhea, 493 (31%) for syphilis and 591 (37%) for HIV. Four hundred thirty-eight (28%) of encounters had screening that included all four tests.ConclusionCollaborative and practical interventions aimed at improving syphilis/HIV testing have resulted in dramatic increases in syphilis, HIV, and comprehensive STI screening (31-, 19-, 280-fold, respectively) over a relatively short post-intervention period. Additional steps are planned with the goal to further increase screening rates and improve linkage to prevention and treatment programs.Disclosures All authors: No reported disclosures.

96 Appropriate Stroke Prophylaxis Action After US Emergency Department Diagnosis and Discharge of Atrial Fibrillation and Flutter Patients

Oral anticoagulation (OAC) reduces stroke and mortality risk in patients with nonvalvular atrial fibrillation and flutter (AFF). The incidence of US emergency department (ED) OAC initiation is poorly understood, as are the appropriate actions following discharge. We examined stroke prophylaxis actions on, and shortly following, ED discharge of stroke-prone AFF patients in a large integrated health care delivery system. We included all adults with a primary diagnosis of nonvalvular AFF, high stroke risk (CHA2DS2-VASc ≥2), and no recent (<90d) OAC at discharge from 21 EDs in Kaiser Permanente Northern California between 2010-2017. Rates of appropriate stroke prevention action were calculated for all eligible discharges per calendar year. Actions were defined as either (1) an OAC prescription by an ED or follow-up provider, (2) a referral to a pharmacy-led anticoagulation management service (AMS), or (3) receipt of both an OAC prescription and AMS referral, within 10 days of ED discharge. We estimated appropriate OAC action (yes/no) with a mixed logistic model with sex, age, race, Hispanic ethnicity, stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) risk and year as a fixed effect, and accounting for clustering by patient. Among 10,281 eligible ED discharges, mean age was 73.7 (STD 11.4) years, 61% were female, and mean CHA2DS2-VASc score was 3.7 (STD 1.62). From 2010 to 2017, there was steady increase in patients receiving both an OAC prescription and referral to AMS, 16.0 to 27.9% (Figure). The rate of no intervention decreased from 82.4 to 65.0% of eligible patients. Factors inversely associated with stroke prevention action within 10 days of ED discharge include female sex (aOR 0.79, 95% CI 0.71-0.88), age >74 years (0.59, 0.45-0.76) vs <64yo, high bleeding risk by HAS-BLED score (0.70, 0.58-0.85) vs low risk respectively, and highest stroke risk (CHA2DS2-VASc score 6-9) (0.70, 0.60-0.84) vs lower risk (CHA2DS2-VASc scores 2-4). The odds of receiving any action was 2.6 times higher in 2017 compared to 2010 (aOR 2.60, 2.08-3.24). Within a community-based ED population of AFF patients at high-stroke risk, the rate of appropriate stroke prevention action increased over the 7-year study period. However, there remains an opportunity to improve AFF thromboprophylaxis as more than half of the eligible patients in 2017 were not receiving appropriate stroke prevention action within 10 days of their index visit. Additionally, female sex and those greater than 74yo were less likely to receive appropriate action compared to men and those younger than 65yo. The undertreatment of those greater than 74yo suggests a misunderstanding of the net clinical benefit associated with OAC in the elderly. Furthermore, opportunities to address sex disparities exist as we seek to improve stroke prophylaxis in nonvalvular AF patients discharged from the ED.

Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review.

IntroductionBronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity.MethodsA retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant.ResultsThe mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96–7.75)) versus not (4.70 (4.20–5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6–2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (–0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively.ConclusionsA large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.

Profile of Interfacility Emergency Department Transfers

The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers. We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training. The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest. Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Structural competency in emergency medicine services for transgender and gender non-conforming patients

In this formative qualitative research, we draw upon the concepts of structural vulnerability and structural competency to examine how transgender and gender non-conforming (TGGNC) patients and healthcare personnel experience service delivery in Emergency Departments (EDs), and how this experience can be improved upon. Between October 2016 and June 2017, we undertook 31 semi-structured interviews with TGGNC patients (n = 11) and physicians (n = 6), nurses (n = 7), and non-clinical staff (n = 7) in four community-based EDs in New Mexico. Our iterative coding and analysis process resulted in eight sets of findings: (1) reasons why TGGNC patients seek care from EDs; (2) perceptions about and experiences of TGGNC patients; (3) relevance of gender identity and sex at birth; (4) bureaucracy and communication; (5) spatial considerations; (6) preparing providers and staff to care for TGGNC patients; (7) the lack of resources for structural prescriptions; and (8) respect, humanity, and sameness. Findings suggest that structural issues adversely impact the health and wellbeing of TGGNC patients and service-delivery practices in the ED. We describe study implications for training ED personnel and modifying this practice setting to prevent delayed care and ensure appropriate services for TGGNC patients in need of structurally competent emergency medicine.

1492. Chlamydia, Gonorrhea, Syphilis and HIV Screening among Men Presenting with STI-Related Complaints at a Community-Based Emergency Department in Columbus, Ohio: A 5-Year Retrospective Study

BackgroundSexually transmitted infections (STIs) disproportionally affect individuals living in poor and underserved areas of the United States. Emergency Departments (ED) are often the only point of healthcare access for these at-risk individuals. As such, the ED often serves a key role in STI screening. The purpose of this study was to review STI screening practices for men at an urban and community-based ED affiliated with a large academic medical center in Columbus, Ohio.MethodsRetrospective review of all ED visits from January 2012 to December 2017. A total of 279,929 patient-visits were analyzed for male patients by (1) exposure to an STI (2) STI-related symptoms (penile discharge/pain, scrotal/testicular pain/swelling). We analyzed the demographic characteristics of men who presented to the ED with an STI-related complaint and compared those who underwent STI screening (chlamydia, gonorrhea, syphilis or HIV) to those that did not.ResultsTable 1.Men with STI-Related Chief Complaints (n = 3,281)Any STI Testing Done 2,274 (69.4%)No STI Testing Done 1,003 (30.6%)Race Black2,112 (92.8%)809 (80.6%) White109 (4.7%)138 (13.7%) Other53 (2.3%)56 (5.5%)Median age (IQR)30 (23–44)27 (23–36)Presenting Complaint Males exposed to STI 1,459 (14.9%)1,120 (76.8%)339 (23.2%) Males with symptoms 1,809 (20.9%)1,154 (63.8%)655 (36.2%)ConclusionOver a 5-year period, screening for chlamydia, gonorrhea for men presenting with STI-related complaints was adequate. However, syphilis and HIV screening was very low among men presenting to an urban and community-based ED with an STI-related complaint. A separate analysis for women is being done. There is an urgent need to identify and eliminate barriers to syphilis and HIV screening in ED’s that serve at-risk populations.Testing Done (n = 2,274)Chlamydia2,269 (99.7%)Gonorrhea2,267(99.6%)Syphilis33 (1.4%)HIV1 (<0.1%)Disclosures All authors: No reported disclosures.