Emergency Department Diagnosis Research Articles

Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index.

To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI). We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics. There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n=140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models. Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.

POCUSTO DIFFERENTIATE DYSPNEAPRESENTING TO EMERGENCY DEPARTMENT

Background: Emergency department(ED) faces challenges in diagnosis and management of patients presenting with acute dyspnea due to resource limited settings. Hence the present study was conducted with the main aim of evaluating a diagnostic strategy using point of care ultrasonography (POCUS) to distinguish patients presenting with acute dyspnea to ED into different diagnostic categories for timely management. Methods: This is a prospective cohort study conducted with total of 50 patients. To assess the diagnostic accuracy of using POCUS in evaluating patients presenting with dyspnea as a predominant complaint to ED. POCUS includes lung-cardiac-IVC, lung usg to identify( diffuse B lines, lung sliding sign, consolidation, pleural effusion etc.,), cardiac usg for left ventricular function, right atrial and right ventricular enlargement, pericardial effusion, cardiac tamponade, inferior vena cava(IVC) diameter and collapsibility. Later, out of nine POCUS diagnosis defined in the study algorithm patients were treated and compared with final hospital diagnosis to estimate the accuracy of this strategy. Results: ED diagnosis of dyspnea using the diagnostic strategy proposed in the study was in compliance with final hospital diagnosis with high agreement in 86% of patients with Kappa statistic = 0.798 (p&lt;0.001) which is statisticaly significant.Acute decompensated heart failure (ADHF) was the most common diagnosis. 98.69% and 96.23% was the sensitivity and specificity of the diagnostic strategy used in this study to identify ADHF. A significant (p&lt;0.01) proportion of patients presenting with dyspnea had Presence of ARDS with ADHF. Conclusion:Incorporating POCUS by lung-cardiac-IVC into routine clinical evaluation yielded a higher accuracy in differentiating causes of dyspnea in ED, and hence this diagnostic strategy could be recommended even in resource-limited setting.

Recurrent Infantile Hypertrophic Pyloric Stenosis in the Emergency Department: A Case Report.

Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of infant vomiting. Emergency department (ED) diagnosis is usually made by pyloric ultrasound and treated by pyloromyotomy. An eight-week-old boy with a history of IHPS about six weeks status post pyloromyotomy presented to the ED with vomiting and failure to thrive, and a critically narrowed pylorus was identified by ultrasound. An upper gastrointestinal series confirmed recurrent pyloric stenosis, necessitating another pyloromyotomy. Prolonged vomiting after pyloromyotomy should be concerning for recurrent IHPS. Upper gastrointestinal series should augment ultrasound to diagnose recurrent IHPS and determine whether a second pyloromyotomy is warranted.

Factors Associated with Anticoagulation Initiation for New Atrial Fibrillation in an Urban Emergency Department.

To explore factors associated with anticoagulation (AC) initiation after atrial fibrillation (AF) diagnosis. Retrospective cohort study. Urban medical center. Adults with emergency department (ED) diagnosis of new onset AF from 1/1/2017-1/1/2020 discharged home. We compared patients initiated on AC, our primary outcome, to those not initiated on AC. Stroke, major bleeding, and AC initiation within 1 year of visit were secondary outcomes. We hypothesized that minority race and non-English language preference are associated with failure to initiate AC. Of 111 patients with AF, 88 met inclusion criteria. Mean age was 65 (SD 15); 47 (53%) were women. 49 (56%) patients were initiated on AC. Age (61 vs 68 years; P=.02), non-English language (28% vs 10%; P=.03), leaving ED against medical advice (AMA) (36% vs 14%; P=.04), and CHA2DS2-VASc score of 1 (41% vs 6%; P<=.001) were associated with no AC initiation. There were no associations between patient-reported race/ethnicity and AC. Cardiology consultation (83.67% vs 30.78%; P<.0001) and higher median CHA2DS2-VASc score (3[2-4]) vs. 2[1-4]; P=.047) were associated with AC. Of 73 patients with follow-up data at 1 year, 2 (8%) not initiated on AC had strokes, 2 (4%) initiated on AC had major bleeds, and 15 (62.5%) not initiated on AC in the ED subsequently were initiated on AC. More than half of ED patients with new AF eligible for AC were initiated on it. Work to improve AC utilization among patients with new AF who left AMA from ED and those who prefer to communicate in a non-English language may be warranted.

Globe Rupture – A Case Report and Review of Emergency Department Diagnosis and Management

Globe ruptures, while uncommon, must be promptly recognized to optimize the possibility of preserving vision. Differentiating open globe injuries from corneal abrasions, hyphema, and other ocular injuries is critical. When a globe rupture is identified, prompt ophthalmology consultation, placement of a rigid eye shield, administration of prophylactic systemic antibiotics (and antifungals with an appropriate history), and a tetanus vaccine update (if needed) are key to a successful outcome, so long as the visual prognosis is not dismal. We describe a case of ocular trauma presenting as a blood blister adherent to the cornea, which was initially assessed (by the triage nurse) to be a blood clot but later identified as a globe rupture. We include a discussion of globe rupture recognition and its management by the emergency department.

353 The Use of Simulation Ultrasound to Train Emergency Clinicians in Transvaginal Ultrasound

Pelvic ultrasound is useful for rapid triage and diagnosis of emergency department (ED) patients in their first trimester of pregnancy who present with vaginal bleeding or abdominal pain. The objective of this study was to measure comfort and competency levels with transabdominal and transvaginal ultrasound before and after a brief educational session using transvaginal simulation training to assess the efficacy of the intervention.

Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department.

Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED. This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automatically once signed. We measured current procedural terminology (CPT) codes 99291 or 99292 (representing CCS rendered) for 8 months before and after deployment to identify CCS documentation rates. We performed state-space Bayesian time-series analysis to evaluate the causal effect of our intervention on CCS documentation capture. We used monthly ED volume and monthly admission rates as covariate time-series for model generation. The study included 92,350 ED patients with an observed mean proportion CCS of 3.9% before the intervention and 5.8% afterward. The counterfactual model predicted an average response of 3.9% [95% CI 3.5-4.3%]. The estimated absolute causal effect of the intervention was 2.0% [95% CI 1.5-2.4%] (p = 0.001). A DDS tool measurably increased ED CCS documentation. Attention to user workflows and collaboration with compliance and billing teams avoided alert fatigue and ensures compliance.

Reducing Unnecessary 'Admission' Chest X-rays: An Initiative to Minimize Low-Value Care.

Introduction Internal medicine admission services often request a baseline admission chest X-ray (CXR) for patients already admitted to the emergency department (ED) and who are waiting for inpatient beds, despiterarely providing clinical value. Adverse consequences of such CXRs include unnecessary radiation exposure, cost, time, and false positives, which can trigger a diagnostic cascade. Extraneous CXRs performed on already-admitted ED patients can delay inpatient transfer, thereby increasing boarding and crowding, whichin turnmay affect mortality and satisfaction. In 2016, our ED and internal medicine hospitalist services implemented guidelines (reflecting those of the American College of Radiology) to reduce unnecessary admission CXRs. All relevant providers were educated on the guideline. The primary aim of this study was to determine if there were changes in the percentage of patients with pre-admission and admission CXRs following guideline implementation. Our secondary aim was to determine which patient characteristics predict getting a CXR. Methods All ED and internal medicine hospitalist providers were educated once about the guideline. We performed a retrospective analysis of pre- vs. post-guideline data. Patients were included if admitted to the internal medicine service during those timeframes with an admission diagnosis unrelated to the cardiac or pulmonary systems. A CXR performed during ED evaluation prior to the admission disposition time was recorded as "pre-admission," andif performed after disposition time it was recorded as "admission." A CXR was "unwarranted" if the admission diagnosis did not suggest a CXR was necessary. The numerator was the number of unnecessary admissionCXRs ordered on patients with diagnoses unrelated to the cardiac or pulmonary systems (minus those with a pre-admission CXR); the denominator was the number of such admissions (minus those with a pre-admission CXR). Variables of interest that might influence whether a CXR was ordered were age, gender, respiratory rate ≥20,cardiac- or pulmonary-related chief complaint, ED diagnosis category, or past medical history. Results Among admitted patients with diagnoses that did not suggest a CXR was warranted, there was no change in the percentage of admission CXRs (21.7% to 25.6%, p = 0.2678), whereas the percentage with pre-admission CXRs decreased (66.6% to 60.7%, p = 0.0152). This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated (p = .0121). In multivariate analysis, risk factors for an unwarranted CXR were age >40 (risk ratio (RR) = 2.9) and past medical history of cardiovascular disease (e.g., myocardial infarction, atrial fibrillation), renal disease, or hyperkalemia. Conclusion This educational initiative was not associated with the intended decrease in ordering unwarranted admission CXRs among ED boarding patients, though there was an unanticipated decrease in pre-admission CXRs. This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated. Organizations interested in reducing processes with little clinical value might adopt a similar program while emphasizing the lack of benefit to admitted patients through iterative educational programs on hospital admitting services.

A curriculum to improve knowledge and skills of nurse practitioners and physician assistants in the pediatric emergency department.

Nurse practitioners (NPs) and physician assistants (PAs) have an important role in delivery of care in a tertiary children's hospital emergency department (ED). Most NPs and PAs have not had any formal training to work in a pediatric ED; although our NPs and PAs had no formal ED training, some were acute care certified. We describe a curriculum designed to improve knowledge and skills of NPs and PAs in the pediatric ED. The curriculum consists of three modules, namely, online lecture series, procedural workshops, and case scenarios in a simulated setting. Module 1 consisted of online lecture on 10 common ED diagnoses. The second module consisted of procedural workshops on lumbar puncture, incision and drainage of abscesses, gastrostomy insertion, and laceration repair. The third module included simulation scenarios on ED-specific cases of seizure in an infant, bronchiolitis and ruptured appendicitis with shock. Each module was evaluated by a survey. Participants rated each item on the survey using a Likert scale response (1 = disagree completely to 5 = agree completely ). Both NPs and PAs demonstrated increase in knowledge scores in posttest 1 vs pretest ( p < .001) and did not show a significant decline in posttest 2 ( p = .073). The mean ratings of components of the online lecture series, workshops, and simulation scenarios were 4.5-4.7, 4.4-4.8, and 4.5-4.7, respectively, with positive comments. This novel curriculum meets the educational needs of NPs and PAs at our institution and can be used as a model to train them at other tertiary care pediatric EDs.

TIME TO GUIDELINE-DETERMINED MEDICAL THERAPY IN PATIENTS WITH DE NOVO HEART FAILURE: A RETROSPECTIVE POPULATION-BASED STUDY FROM ALBERTA, CANADA

TIME TO GUIDELINE-DETERMINED MEDICAL THERAPY IN PATIENTS WITH DE NOVO HEART FAILURE: A RETROSPECTIVE POPULATION-BASED STUDY FROM ALBERTA, CANADA

175 National Trends in Chemical Restraint for Pediatric Behavioral Health Patients in the Emergency Department

175 National Trends in Chemical Restraint for Pediatric Behavioral Health Patients in the Emergency Department

194 Discordance of Pneumonia Diagnoses from Admission to Discharge: A Retrospective Cohort Analysis of 118 Veterans Affairs Emergency Departments

194 Discordance of Pneumonia Diagnoses from Admission to Discharge: A Retrospective Cohort Analysis of 118 Veterans Affairs Emergency Departments

56EMF Augmenting D-dimer Testing for Pulmonary Embolism Rule-out in the Emergency Department With Artificial Intelligence

Pulmonary embolism (PE) is a common emergency department (ED) diagnosis with a greater than 4% mortality rate, resulting in frequent over-testing via computed tomography PE (CT-PE) and exposing patients to the harms of ionizing radiation, iodinated contrasts, and increased costs. Clinical decision rules incorporating D-dimer testing are used to identify patients whose PE risk is below a CT-PE imaging threshold, but are subject to high rates of false positives and inconsistent use. We hypothesized that an artificial intelligence (AI) algorithm would augment existing D-dimer-based risk stratification and identify patients who are unlikely to benefit from imaging.

27 Combining Machine Learning and Network Science to Cluster Emergency Department Chief Complaints and Diagnoses

Study Objectives: Improvements to electronic health record (EHR) systems have enabled the adaptation of emergency care practice to incorporate discrete data capture of chief complaints and clinical diagnoses. However, the number of distinct data elements for complaints and diagnoses is very large. In this study, we sought to apply data science approaches (including network science and unsupervised machine learning) to identify clusters of complaints and diagnoses in the emergency department (ED).

251 Emergency Department Arrival by Ambulance for Patients Receiving a Pulmonary Embolism Diagnosis Is Associated With Hospitalization: Is Coming from Off-site Radiology an Exception?

251 Emergency Department Arrival by Ambulance for Patients Receiving a Pulmonary Embolism Diagnosis Is Associated With Hospitalization: Is Coming from Off-site Radiology an Exception?

206 Children Under 12 Presenting to the Emergency Department With Covid-19

206 Children Under 12 Presenting to the Emergency Department With Covid-19

Evaluation of Diagnostic and Triage Accuracy and Usability of a Symptom Checker in an Emergency Department: Observational Study.

BackgroundSymptom checkers are clinical decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnostic and triage advice and assist users in seeking the appropriate level of care. Little evidence is available regarding their diagnostic and triage accuracy with direct use by patients for urgent conditions.ObjectiveThe aim of this study is to determine the diagnostic and triage accuracy and usability of a symptom checker in use by patients presenting to an emergency department (ED).MethodsWe recruited a convenience sample of English-speaking patients presenting for care in an urban ED. Each consenting patient used a leading symptom checker from Ada Health before the ED evaluation. Diagnostic accuracy was evaluated by comparing the symptom checker’s diagnoses and those of 3 independent emergency physicians viewing the patient-entered symptom data, with the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. The patients completed a usability survey based on the Technology Acceptance Model.ResultsA total of 40 (80%) of the 50 participants approached completed the symptom checker assessment and usability survey. Their mean age was 39.3 (SD 15.9; range 18-76) years, and they were 65% (26/40) female, 68% (27/40) White, 48% (19/40) Hispanic or Latino, and 13% (5/40) Black or African American. Some cases had missing data or a lack of a clear ED diagnosis; 75% (30/40) were included in the analysis of diagnosis, and 93% (37/40) for triage. The sensitivity for at least one of the final ED diagnoses by Ada (based on its top 5 diagnoses) was 70% (95% CI 54%-86%), close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated the Ada triage decisions as 62% (23/37) fully agree and 24% (9/37) safe but too cautious. It was rated as unsafe and too risky in 22% (8/37) of cases by at least one physician, in 14% (5/37) of cases by at least two physicians, and in 5% (2/37) of cases by all 3 physicians. Usability was rated highly; participants agreed or strongly agreed with the 7 Technology Acceptance Model usability questions with a mean score of 84.6%, although “satisfaction” and “enjoyment” were rated low.ConclusionsThis study provides preliminary evidence that a symptom checker can provide acceptable usability and diagnostic accuracy for patients with various urgent conditions. A total of 14% (5/37) of symptom checker triage recommendations were deemed unsafe and too risky by at least two physicians based on the symptoms recorded, similar to the results of studies on telephone and nurse triage. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments.

The impact of high-frequency linear transducer on the accuracy of pelvic ultrasound in early pregnancy pelvic pain and bleeding

IntroductionThe primary concern of emergency physicians (EPs) in symptomatic patients in their early pregnancy is to rule out ectopic pregnancy by identifying a definite intrauterine pregnancy (IUP). Then an assessment of viability is required for the IUPs. Although transvaginal ultrasound (TVUS) stands as the best modality for these patients, it is not available in most emergency settings. This study aimed to investigate the effects of high-frequency linear transducers (HFLT) on the accuracy of point-of-care ultrasound (POCUS) for detection of IUP and the agreement between EPs and obstetricians for patients' diagnosis. MethodA convenience sample of pregnant patients who presented to the emergency department (ED) with vaginal bleeding and abdominopelvic pain was included. The characteristics of diagnostic tests of transabdominal POCUS performed by EPs were compared to TVUS. ResultsThe study population was finalized as 143 patients. For the definite IUP, the diagnostic accuracy of POCUS was 93.0%, with a sensitivity of 89.0%, a specificity of 100%, compared to an accuracy of 97.9% for POCUS plus HFLT with a sensitivity of 96.7%, a specificity of 100%. For the identification of fetal cardiac activity (FCA), utilizing HFLT improved the diagnostic accuracy to 97.9% (from 94.4%) and sensitivity to 95.5% (from 88.1%). In addition, the agreement between the EPs and obstetricians concerning the classification of ED diagnosis was excellent (agreement: 96.5%, kappa: 0.943, p < 0.0001). ConclusionPOCUS plus HFLT performed by EPs in evaluating symptomatic patients in their first-trimester pregnancy improves the accuracy to a non-inferior level compared to TVUS performed by obstetricians. Hence, EPs can securely rely on POCUS to confirm IUP and FCA. However, they should be cautious about using it as a rule-out tool. Moreover, HFLT use could enhance the accuracy of POCUS in viability assessment as an alternative to TVUS.

Younger Age and Longer Case Times Associated With Emergency Department Visits After Cataract Surgery

To characterize the frequency, reasons, hospital costs, and risk factors for emergency department (ED) visits within 30 days of cataract surgery. Retrospective cohort study. A retrospective review of all cataract surgeries at Duke Health between 2013 and 2021 was conducted. Demographics, case characteristics (length, complexity by billing codes, anesthesia type), ED visit findings, and hospital costs were collected. Logistic regression models were used to determine the odds of ED visits based on several risk factors. Of 34246 patients (57656 eyes) undergoing cataract surgery at Duke Health from 2013 to 2021, a total of 607 patients (1.77%) had 680 ED visits within 30 days of surgery. The most common ED diagnosis was cardiovascular (24.4%), whereas ocular complaints constituted 15.4% of visits. The most common ocular diagnoses were high intraocular pressure, rebound iritis, and posterior vitreous detachment. Hospital costs were lowest for ocular diagnoses (mean $467.72) and highest for trauma diagnoses (mean $4660.55). Risk factors for ED visits included case lengths greater than 30 minutes (OR 2.1, 95% CI 1.56-2.83, P < .001), the combination of Monitored Anesthesia Care (MAC) and retrobulbar anesthesia or general anesthesia (OR 2.98, 95% CI 1.73-5.12, P < .001), and age less than 70 years (OR 1.39, 95% CI 1.16-1.65, P < .001). ED visits within 30 days of cataract surgery are uncommon. Longer case lengths, anesthesia other than MAC alone, and younger age are associated with higher odds of ED visits.

A Study of NT-ProBNP and ETCO2 in Patients Presenting with Acute Dyspnoea

Objectives: In patients presenting with acute dyspnoea in the emergency department (ED), the early and correct diagnosis may present a significant clinical challenge. The most common diagnoses of acute shortness of breath and manifesting signs of respiratory distress are decompensated heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), pulmonary embolism (PE), asthma, and acute respiratory distress syndrome (ARDS) and other causes like anaemia. The aim of the study was to measure NT-pro brain natriuretic peptide (BNP) and exhaled end-tidal carbon dioxide (ETCO2) in patients presenting with dyspnoea. Material and Methods: This prospective, cross-sectional and observational study was performed at the Government Medical College and Hospital, Nagpur, between October 2019 and October 2021 in patients admitted to the medicine intensive care unit. Three groups of patients were compared: (1) HF-related acute dyspnoea group (n = 52), (2) pulmonary (COPD/PE)-related acute dyspnoea group (n = 31) and (3) sepsis with ARDS-related dyspnoea group (n = 13). All patients underwent initial clinical examination with a recording of initial vital parameters along with on-admission ETCO2 measurement, NT-proBNP testing, arterial blood gas testing, lung ultrasound examination, 2D echocardiography, chest X-rays, and other basic diagnostic laboratory testing. Results: We included 96 patients during the study period. Median NT-proBNP was found to be maximum for the HF group (11,480 pg/ml) followed by the sepsis group (780 pg/ml) and pulmonary group (231 pg/ml). The mean ETCO2 value was found to be maximum in the pulmonary group (48.610 mmHg) followed by HF (31.51 mmHg) and the sepsis group (19.46 mmHg). All results were found to be statistically significant (P &lt; 0.05). Conclusion: NT-proBNP has high diagnostic accuracy in differentiating acute HF-related dyspnoea from pulmonary (COPD and ARDS)-related acute dyspnoea. The higher levels of ETCO2 help in diagnosing patients with COPD.