ED Patients Research Articles

Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation

BackgroundAddressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017...

A novel strategy to induce penile erection during penile doppler ultrasound: oral sildenafil administration plus alprostadil injection

Objectives To evaluate the efficacy of a novel approach to achieve the optimal penile erection during the penile doppler ultrasound (PDU) examination, which was oral sildenafil combined alprostadil injection. Materials and Methods A total of 60 ED patients were enrolled in our prospective study, and they were randomly assigned to two group with different PDU order. The approaches assisted the PDU included two models, mode A meaning injection of 15 μg alprostadil and model B meaning oral sildenafil 100 mg plus injection of 15 μg alprostadil. The PDU parameters were measured continuously before induced erection, and 5, 10, 15, 20, 25 min. Results Each group included 30 ED patients with similar clinical characteristics. After pooling the results together, the PSV, EDV, and RI were all improved significantly, when adding the oral sildenafil administration to assist PDU. Also, the clinical response of oral sildenafil administration plus alprostadil injection was better than that in alprostadil injection alone (p = 0.016). The arterial ED were decreased from 31.67% to 15.00% with the P value 0.031, and the mixed ED was also decreased statistically (23.33% vs 8.33%, p = 0.024). Conclusion Oral sildenafil administration plus alprostadil injection could improve the diagnostic accuracy of PDU.

Features of attachment in women with eating disorders

IntroductionEating disorders (ED), especially anorexia nervosa, are known to be the most associated with high mortality rates among psychiatric conditions. In many cases, they are resistant to treatment because patients tend to show low compliance, concealing symptoms from doctors. Body image concerns may affect communication and hinder building connections with people, making patients feel alienated.ObjectivesThe study aimed to examine the specific characteristics of attachment styles and evaluate their interrelationships with psychological features in women with eating disorders.Methods A total of 52 women with a clinical diagnosis of eating disorder (namely, 26 with anorexia nervosa (AN) and 26 with bulimia nervosa (BN)) and 43 healthy controls were included in the study. All participants completed the following psychometric scales: Relationship Questionnaire (RQ), Experience in Close Relationships (ECR), Relationship Profile Test (RPT), and Multidimensional Perfectionism Scale (MPS). The Kolmogorov-Smirnov normality test was applied, confirming a non-normal distribution of the sample; therefore, the non-parametric Mann-Whitney test and Spearman statistics were administered.ResultsThe results show a marked difference between the two groups. In the ED patients’ group, only 15% of respondents classified their attachment style as secure, compared to 37% of the participants in the control group. 85% of women in the ED group identified themselves as having one of the insecure attachment styles (anxious, avoidant, or disorganized). The level of relationship anxiety and the rate of relationship avoidance in the respondents of the ED group is 27% and 19% higher, respectively, compared to the control group. Likewise, the level of destructive interpersonal overdependence is 20% higher in the ED patients’ group respondents, whereas healthy dependence is 18% lower compared to the controls. The respondents with ED showed 18% higher self-oriented perfectionism and 39% higher socially prescribed perfectionism. A direct correlation between avoidant attachment style and destructive interpersonal overdependence was found in women with diagnoses belonging to the ED group. When comparing AN and BN patients, no statistically significant differences in the distribution and peculiarities of attachment styles in the anorexia and bulimia groups were found.ConclusionsThe study has proved the hypothesis that insecure attachment is more common among women with eating disorders than those without the diagnosis. We suggest a more profound scientific elaboration of the attachment in ED patients to increase the level of compliance of this group of patients, to improve the effectiveness and reduce the duration of treatment, and develop new therapeutic approaches to cure this disease.Disclosure of InterestNone Declared

Topical Anesthetics Can Safely Be Given to ED Patients with Corneal Abrasion Pain

Topical Anesthetics Can Safely Be Given to ED Patients with Corneal Abrasion Pain

(O-10) CLINICAL PROFILE AND SATISFACTION LEVEL OF PATIENTS UNDERGOING PENILE PROSTHESIS IMPLANTATION AT PEDRO ERNESTO UNIVERSITY HOSPITAL (HUPE/UERJ) 2018-2022

Abstract Introduction Erectile dysfunction (ED) can significantly impact couples' sexual quality of life, with penile prosthesis implants often yielding satisfaction rates of up to 90%. This treatment remains underutilized, less than 5% of refractory ED patients to undergo this therapy. This study aims to assess the satisfaction levels of patients who have undergone penile prosthesis implantation and explore associated factors. Methods We reviewed 48 medical records of patients who underwent penile prosthesis implantation between 2018-2022 and administered satisfaction questionnaires 6 months after the procedure. Results 93% expressed satisfaction post-surgery, with 66% reporting increased libido. Additionally, 83% noted ease in achieving penetration, 75% were content with the prosthesis size, and 95% stated willingness to undergo the surgery again. Common causes of sexual dysfunction were post-radical prostatectomy (45%), followed by diabetes mellitus (22%). Peyronie's disease was the etiology in 6% of cases, and priapism in 2%. The average age was 63 years (range: 27-80), with 20% being obese, 37% having diabetes mellitus, and 56% experiencing systemic arterial hypertension. Approximately 20% of procedures presented complications, surgical wound infection being the most common and prosthesis extrusion the most severe. Discussion Literature identifies predictors associated with satisfaction after penile prosthesis implantation, such as Peyronie's disease, BMI > 30, post-radical prostatectomy, implant type, postoperative complications, and patient age; our study revealed that only 7% expressed dissatisfaction, primarily due to postoperative complications. Conclusion Penile prosthesis implantation proves to be a safe procedure with a high success rate and satisfaction level. Dissatisfaction primarily arises from postoperative complications, emphasizing the importance of offering this therapeutic option to patients with severe ED. Financing No conflict.

Broselow Tape vs Provider Weight Estimation in Pediatric ED Patients

Broselow Tape vs Provider Weight Estimation in Pediatric ED Patients

Comparison of Treatment Approaches and Subsequent Outcomes within a Pulmonary Embolism Response Team Registry.

To characterize the association between pulmonary embolism (PE) severity and bleeding risk with treatment approaches, outcomes, and complications. Secondary analysis of an 11-hospital registry of adult ED patients treated by a PE response team (August 2016-November 2022). Predictors were PE severity and bleeding risk. The primary outcome was treatment approach: anticoagulation monotherapy vs. advanced intervention (categorized as "immediate" or "delayed" based on whether the intervention was received within 12 hours of PE diagnosis or not). Secondary outcomes were death, clinical deterioration, and major bleeding. Of the 1832 patients, 139 (7.6%), 977 (53.3%), and 9 (0.5%) were classified as high-risk, intermediate-high, intermediate-low, and low-risk severity, respectively. There were 94 deaths (5.1%) and 218 patients (11.9%) had one or more clinical deterioration events. Advanced interventions were administered to 86 (61.9%), 195 (27.6%), and 109 (11.2%) patients with high-risk, intermediate-high, and intermediate-low severity, respectively.Major bleeding occurred in 61/1440 (4.2%) on ACm versus 169/392 (7.6%) with advanced interventions (p <0.001): bleeding withcatheter-directed thrombolysiswas 19/145 (13.1%) versus 33/154(21.4%) with systemic thrombolysis,p= 0.07. High risk was twice as strong as intermediate-high risk for association with advanced intervention (OR: 5.3 (4.2 and 6.9) vs. 1.9 (1.6 and 2.2)). High risk (OR: 56.3 (32.0 and 99.2) and intermediate-high risk (OR: 2.6 (1.7 and 4.0)) were strong predictors of clinical deterioration. Major bleeding was significantly associated with advanced interventions (OR: 5.2 (3.5 and 7.8) for immediate, 3.3 (1.8 and 6.2)) for delayed, and high-risk PE severity (OR: 3.4 (1.9 and 5.8)). Advanced intervention use was associated with high-acuity patients experiencing death, clinical deterioration, and major bleeding with a trend towards less bleeding with catheter-directed interventions versus systemic thrombolysis.

Does erectile dysfunction predict cardiovascular risk? A cross-sectional study of clinical characteristics in patients with erectile dysfunction combined with coronary heart disease.

Erectile Dysfunction (ED) is a common sexual dysfunction in men who are unable to consistently obtain and maintain sufficient penile erection to accomplish a satisfactory sexual life. ED is currently considered to be a predictor of cardiovascular disease (CVD), but few studies have observed the association between ED and clinical features of coronary heart disease (CHD). An investigation of the association between ED and clinical characteristics of CHD was carried out using a cross-sectional study design. This cross-sectional single-center study was conducted in the Department of Cardiology and included 248 patients. Associations between patients' general information, underlying disease information, coronary heart disease information, and ED severity were statistically and analytically analyzed using SPSS 26.0 software. Patients with comparable clinical characteristics were grouped together using K-means clustering. Finally, ordered logistic regression analysis was performed for general and underlying disease information. In the comparison of general data, age, education, and weekly exercise were associated with the distribution of ED severity. In the comparison of underlying disease information, the number of underlying diseases, hypertension, diabetes, hyperlipidemia, anxiety state, and depressive state were associated with the distribution of ED severity. In the comparison of CHD information, the degree of ED severity was associated with CHD subtypes, lesion sites, number of stenoses, degree of stenosis, and interventional interventions. The time from ED to CHD onset was associated with the subtypes of CHD and the number of stenoses. We clustered the main characteristics of low-risk and high-risk patients and ordered logistic regression analysis found that BMI, smoking, alcoholism, number of underlying diseases, diabetes, anxiety state, and depression state were all risk factors for CHD severity (P < 0.05); the higher the value of the above factors, the more severe the degree of CHD. Age was a protective factor for CHD severity; the younger the patient, the lower the likelihood of myocardial infarction. ED severity and the time from ED to CHD onset may be predictive of coronary heart disease severity. Reducing smoking and alcohol consumption, maintaining a healthy body weight, and regular physical activity are important in preventing CVD in ED patients.

Cellulitis in the Emergency Department: A prospective cohort study with patient-centred follow-up.

There is substantial practice variation in the management of cellulitis with limited prospective studies describing the course of cellulitis after diagnosis. We aimed to describe the demographics, clinical features (erythema, warmth, swelling and pain), patient-reported disease trajectory and medium-term follow-up for ED patients with cellulitis. Prospective observational cohort study of adults diagnosed with cellulitis in two EDs in Southeast Queensland, Australia. Patients with (peri)orbital cellulitis and abscess were excluded. Data were obtained from a baseline questionnaire, electronic medical records and follow-up questionnaires at 3, 7 and 14 days. Clinician adjudication of day 14 cellulitis cure was compared to patient assessment. Descriptive analyses were conducted. Three-hundred patients (mean age 50 years, SD 19.9) with cellulitis were enrolled, predominantly affecting the lower limb (75%). Cellulitis features showed greatest improvement between enrolment and day 3. Clinical improvement continued gradually at days 7 and 14 with persistent skin erythema (41%) and swelling (37%) at day 14. Skin warmth was the feature most likely to be resolved at each time point. There was a discrepancy in clinician and patient assessment of cellulitis cure at day 14 (85.8% vs. 52.8% cured). A clinical response of cellulitis features can be expected at day 3 with ongoing slower improvement over time. Over one third of patients had erythema or swelling at day 14. Patients are less likely than clinicians to deem their cellulitis cured at day 14. Future research should include parallel patient and clinician evaluation of cellulitis to help develop clearer definitions of treatment failure and cure.

Impact of low-intensity extracorporeal shockwave therapy on vascular parameters and sexual function in patients with arteriogenic erectile dysfunction.

Previous published studies have shown an improvement of penile hemodynamic parameters after low-intensity extracorporeal shockwave therapy (Li-ESWT). However, the clinical significance of these findings remains unclear, and definitive selection criteria for Li-ESWT based on preexisting comorbidities have yet to be established. This was an observational study of 113 patients with ED, evaluated between January 2019 and December 2021 in Andrology Unit at the Department of Urology and Renal Transplantation, University of Foggia (Foggia, Italy). Penile dynamic Doppler was performed to evaluate vascular parameters and 5-item version of the International Index of Erectile Dysfunction (IIEF-5) questionnaire was administered to assess the severity of ED. This was repeated 1 month after treatment. Patients with a peak systolic velocity (PSV) <30 cm s -1 were considered eligible for Li-ESWT. Our protocol consisted of 8 weekly sessions with 1500 strokes distributed in 5 different locations along the penis. After treatment, a significant mean (±standard deviation [s.d.]) PSV increase of 5.0 (±3.4) cm s -1 was recorded and 52/113 (46.0%) patients reached a PSV >30 cm s -1 at posttherapeutic penile dynamic Doppler. A clinically significant IIEF-5 score improvement was observed in 7 patients, 21 patients, and 2 patients with mild-to-moderate, moderate, and severe pretreatment ED, respectively. No different outcomes were assessed based on smoking habits, previous pelvic surgery, or use of oral phosphodiesterase-5 inhibitor (PDE5i). On the other side, only 1 (6.7%) in 15 patients with diabetes mellitus showed an IIEF-5 score improvement after Li-ESWT. Shockwave treatment determined a significant increase in PSV and correlated IIEF-5 improvement in ED patients. This advantage seemed particularly evident for moderate ED and was not affected by smoking habits, previous pelvic surgery, and use of PDE5i. Conversely, diabetic patients did not benefit from the treatment.

(028) Intracavernosal Injection of Platelet-Rich Plasma for the Treatment of Erectile Dysfunction: A Meta-Analysis of Randomized Placebo-Controlled Trials

Abstract Introduction Erectile dysfunction (ED) affects 3 to 76.5% of men globally. Appropriate treatments for ED patients are vital to ensure their quality of life. However, the present conservative ED treatments cannot reverse the underlying pathology and often lead to discontinuation due to the lack of efficacy. Regenerative therapies, including platelet-rich plasma (PRP), have been gaining increasing interest for the last few years. Preclinical studies suggest that growth factors in PRP may be beneficial in ED. With the increasing evidence of PRP, a meta-analysis has yet to be conducted to determine its efficacy and safety compared to a placebo. Objective To systematically evaluate PRP's efficacy and safety for treating ED based on randomized placebo-controlled trials (RCTs) results. Methods A comprehensive search on PubMed, Scopus, and EMBASE databases was conducted on June 2023 to find relevant articles following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RCTs in English evaluating PRP's efficacy and safety in treating ED were included. The primary outcomes were the International Index of Erectile Function-Erectile Function (IIEF-EF) score at 1-, 3-, and 6-months post-treatment. The secondary analysis includes the proportion of patients who met the minimal clinically important difference (MCID) of IIEF-EF score, IIEF score for sexual satisfaction and overall satisfaction, peak systolic velocity (PSV) in the cavernousal artery, and the complication rate after treatment. Quality of included studies was assessed using JADAD Score and Cochrane RoB2 tools. Meta-analysis with a random or fixed effects model based on the heterogeneity was performed using Revman 5.4. Results From 183 articles in initial research, three RCTs with low risk of bias were reviewed. We included 103 patients in the PRP group and 106 in the placebo group. The baseline of the evaluated score from both groups was comparable despite variable PRP protocol being used. The pooled analysis showed that PRP is associated with higher IIEF-EF scores at 1, 3, and 6 months follow up compared to placebo with a mean difference (MD) of 2.85 (95% CI, 1.68 – 4.03, p: &amp;lt;0.00001), 2.81 (95% CI, 1.57 – 4.05, p: &amp;lt;0.00001), 3.11 (95% CI, 1.96 – 4.27, p: &amp;lt;0.00001). Similarly, the proportion of patients who met MCID and PSV at follow-up also favoured the PRP group. On contrary, the IIEF score for sexual satisfaction and overall satisfaction domain, as well as VAS score post-injection were comparable between groups. No significant adverse event was reported in any study during follow-up. Conclusions The present meta-analysis suggests that PRP is effective and tolerable as a restorative therapy for managing ED patients compared to a placebo. Nevertheless, additional RCTs with more robust data from larger sample sizes and longer-term follow-ups are required to corroborate the findings. Disclosure No.

(012) Sexual Dysfunction in Men After Failed Hypospadias Repair

Abstract Introduction Hypospadias is commonly treated in childhood, and future sexual function of such patients is sometimes overlooked. Some published reports reveal excellent sexual function following hypospadias repair at long term, while other authors state high prevalence of sexual dysfunction which depends on original position of urethral meatus. Patients with complications of primary hypospadias repair are one of the most difficult subpopulations to evaluate. This is a unique subset of patients who should be described separately from men who underwent successful hypospadias repair. Objective To describe the spectrum of sexual dysfunction in patients with sequelae of failed hypospadias repair and our experience in its management. Methods We evaluated 112 patients with a history of failed hypospadias repair, defined as presence of voiding symptoms or cosmetic problems remaining despite previous surgery or caused by it. Patients’ median age was 29.5 years (range: 18–62). There were no intersex cases. Only 9.8% (11/112) underwent single attempt at surgical reconstruction, the median number of attempts was 3.5 (range: 1–9). Patients with IIEF-EF score ≤ 25 were considered to have erectile dysfunction; those with IIEF-EF ≤ 16 underwent penile doppler ultrasound, penile electromyography and endocrine assessment. Results 64.2% of patients (72/112) were dissatisfied with penile appearance, 40.2% (45/112) had ED, 71.4% (80/112) had ejaculation disorders. Psychogenic ED was diagnosed in 21 patients with preserved non-coital erections and no evidence of organic ED. Median IIEF-EF in ED patients was 20 (range: 8–25). Asthenic ejaculation, delayed ejaculation and anejaculation were present in 63.4% (71/112), 7.1% (8/112) and 3.5% (4/112) patients, respectively. Premature ejaculation was present in 28.6% (32/112) patients, but its association with hypospadias or previous surgery is unlikely. On univariate analysis only the number of previous attempts at surgical repair was a significant predictor of sexual dysfunction following definitive surgery (p = 0.033). Rate of normal sexual function was 37.5%, 23.5% and 9.1% among patients with history of ≤ 3, 4–6 and ≥ 7 procedures, respectively. Conclusions Failed hypospadias repair may lead to a wide spectrum of sexual dysfunction, involving sexual desire, erection and ejaculation. Repeated surgery leads to increased risk of sexual dysfunction which may be devastating for patient’s quality of life. Disclosure No.

(218) The Intimometer: A Brief Psychometric Self-Report Questionnaire

Abstract Introduction Erectile dysfunction (ED) or premature ejaculation (PE) can severely affect the quality of life and wellbeing of both couple members. Sexual health care providers, including andrologists and sexologists, should perceive ED/PE as a collaborative health issue for men and their sexual partners. Thus, this study was designed to better understand the contribution of sexual partners in the treatment of men with ED/PE. Objective We aimed to evaluate the advisability of female (or male, in the case of homosexual patient) partner involvement in the prescription of specific pharmacological therapies in ED/PE patients. Methods We developed a brief psychometric self-report questionnaire tool, Intimometer. This tool consists of two modules (patient and partner versions) for each sexual dysfunction (ED and PE). Each module has 6 items that evaluate the degree of comfort/discomfort about communication, sharing, and partner involvement during the process of drug prescription and intake. The tool can be administered during the first andrological visit to either a single individual (only patient version) or to both members of the couple. The single module can be administered in less than 3 minutes. Each item scores from 0 (extremely unlikely) to 4 (extremely likely), and the total score is computed by the sum of the modules’ items. The total score ranges from 0 to 24, with higher scores endorsing the partner's comfort during treatment of ED/PE. Also, color codes were assigned for responses, low scores (red light) and high scores (green light) or combination of single results (couple administration). Results We hypothesize one cut-off score to identify two categories of responses. A low score signifies that the patient feels uncomfortable sharing drug information, choice, and intake and the involvement of the partner could potentially be harmful during medical treatment. On the contrary, a high score shows the involvement of the partner could improve the treatment’s efficacy and/or compliance, with a high chance of success. The combination of the single results (red, yellow and green) helps to identify the best treatment choice. The red light indicates that prior to medical prescription, the couple undergoes a psycho-sexological assessment to unveil conditions to continue with medical treatment. Yellow light indicates contemporary to medical prescription, psycho-sexological assessment might manage relational issues that could worsen pharmacological treatment. And green light denotes that the instrument could be re-administered after 4 weeks since the first administration, to verify any changes in patient/partner’s perception of medical treatment. Moreover, a re-test is highly recommended in patients whose scores are low or medium. Nevertheless, patients and couples who are classified as “red” or “yellow” light could present any other psychological complications (performance anxiety, fear of rejection, anger towards partner) which can be evaluated by psycho-sexologists. Conclusions This instrument could be beneficial to physicians while prescribing medical therapy and prevent any possible patient dropout and resultant therapy failure, especially in PE and ED patients. The involvement of sexual partners in the diagnostic process, education, counseling, and treatment choice is pivotal in improving the overall quality of life and sexual experiences for couples. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: 2Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy.

Topical Diclofenac Versus Oral Ibuprofen Versus Diclofenac + Ibuprofen for Emergency Department Patients With Acute Low Back Pain: A Randomized Study

IntroductionTopical non-steroidal anti-inflammatory drugs (NSAIDs) are useful for a variety of musculoskeletal injuries. It is not known whether topical NSAIDs should be used for patients presenting with acute non-radicular musculoskeletal low back pain (LBP). MethodsWe conducted a randomized, placebo-controlled double-blind study in which ED patients 18-69 years with acute, non-traumatic, non-radicular, musculoskeletal LBP were randomized at the time of discharge to treatment with oral ibuprofen 400mg orally + placebo topical gel, 1% diclofenac topical gel + oral placebo, or ibuprofen 400mg + 1% diclofenac topical gel. We measured outcomes using the Roland Morris Disability Questionnaire (RMDQ), a 24-item yes/no instrument about the impact of back pain on a respondent’s daily activities. The primary outcome was change in RMDQ between ED discharge and two days later. Medication related adverse events were elicited by asking whether the study medications caused any new symptoms. Results3281 patients were screened for participation and 198 were randomized. Overall, 36% of the population were women, the mean age was 40 years (SD 13), and the median RMDQ score at baseline was 18 (25th, 75th percentile: 13, 22) indicating substantial low back related functional impairment. 183 (92%) participants provided primary outcome data. By two days after the ED visit, the ibuprofen + placebo group had improved by 10.1(95%CI 7.5 to 12.7), the diclofenac gel + placebo group by 6.4(95%CI 4.0 to 8.8), and the ibuprofen + diclofenac gel by 8.7(95%CI 6.3 to 11.1). The 95%CI for between group differences were as follows-- ibuprofen versus diclofenac: 3.7 (0.2, 7.2); ibuprofen versus both medications 1.4 (-2.1, 4.9); diclofenac versus both medications -2.3 (-5.7, 1.0). Medication related adverse events were reported by 3/60 (5%) ibuprofen patients, 1/63 (2%) diclofenac patients, and 4/64 (6%) patients who got both. ConclusionsAmong patients with non-traumatic, non-radicular acute musculoskeletal low back pain discharged from an ED, topical diclofenac was probably less efficacious than oral ibuprofen. It demonstrated no additive benefit when co-administered with oral ibuprofen.

Radiologists predict differential resource utilization but not clinical outcome in emergency department patients imaged with ultrasound for right upper quadrant pain.

Radiologists with diverse training, specialization, and habits interpret imaging in the Emergency Department. It is necessary to understand if their variation predicts differential value. The purpose of this study was to determine whether attending radiologist variation predicts major clinical outcomes in adult Emergency Department patients imaged with ultrasound for right upper quadrant pain. Consecutive ED patients imaged with ultrasound for RUQ pain from 10/8/2016 to 8/10/2022 were included (N = 7097). The primary outcome was prediction of hospital admission by signing attending radiologist. Secondary outcomes included: ED and hospital length of stay (LOS), 30-day mortality, 30-day re-presentation rate, subspecialty consultation, advanced imaging follow up (HIDA, MRI, CT), and intervention (ERCP, drainage or surgery). Sample size was determined a priori (detectable effect size: w = 0.06). Data were adjusted for demographic data, Elixhauser comorbidities, number of ED visits in prior year, clinical data, and system factors (38 covariates). P-values were corrected for multiple comparisons (false discovery rate-adjusted p-values). The included ultrasounds were read by 35 radiologists (median exams/radiologist: 145 [74.5-241.5]). Signing radiologist did not predict hospitalization (p = 0.85), abdominopelvic surgery or intervention within 30 days, re-presentation to the Emergency Department within 30 days, or subspecialty consultation. Radiologist did predict difference in Emergency Department length of stay (p < 0.001) although this difference was small and imprecise. HIDA was mentioned variably by radiologists (range 0-19%, p < 0.001), and mention of HIDA in the ultrasound report increased 10-fold the odds of HIDA being performed in the next 72h (odds ratio 10.4 [8.0-13.4], p < 0.001). Radiologist variability did not predict meaningful outcome differences for patients with right upper quadrant pain undergoing ultrasound in the Emergency Department, but when radiologists mention HIDA in their reports, it predicts a 10-fold increase in the odds a HIDA is performed. Radiologists are relied on for interpretation that shapes subsequent patient care, and it is important to consider how radiologist variability can influence both outcome and resource utilization.

Performance of the European Society of Cardiology 0/1-hour algorithm with high-sensitivity cardiac troponin T at 90 days among patients with known coronary artery disease

BackgroundThe European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥ 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD. MethodsWe performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017–9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test. ResultsThe STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8–98.8) among patients with known CAD and 98.8% (95%CI 97.6–99.5) in patients without known CAD (p = 0.09). ConclusionPatients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD. Trial registrationHigh-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).

The decrease of ED patient boarding by implementing a stock management policy in hospital admissions

The presence of congestion is a common scenario in tertiary-level hospitals worldwide. Current research suggests that an increase in hospital bed capacity is not a long-term solution given that patient demand adapts to added capacity. Recent literature suggests the need for the implementation of a policy of inter-hospital transfers to divert patients to outpatient priority services or home care. This policy has proven to be effective in reducing ED boarding without compromising patient safety. However, determining the required number of patients to be admitted is key. The dynamic nature of hospital bed availability and discharges requires an admission process able to be in synchrony with those variations. A mismatch between patient demand and hospital admissions will result in either ED boarding or idle capacity. The purpose of this paper is to introduce a methodology to support the process of hospital admissions by providing as an input a threshold for the number of patients to be admitted. The methodology is tested using a system dynamics model that replicates one year of operations of a tertiary-level hospital. The simulations reveal the potential of the methodology to decrease the ED inpatient boarding rate as well as ED and hospital length of stay.

Examining food insecurity in a regional New Zealand emergency department: A cross-sectional study.

To determine the prevalence of food insecurity (FI) among patients in a regional New Zealand ED, factors associated with FI and feasibility of an ED-based FI screening programme with voluntary social work (SW) follow up. Cross-sectional study of patients presenting to the Whangarei Hospital ED, using the validated two-item Hunger Vital Sign screening tool to assess for FI. Participants were offered SW follow up to discuss community food resources. Of the 300 participants who completed the questionnaire, 111 (37.0%, 95% confidence interval [CI] 32.0-43.0) were food insecure. Factors associated with FI include Māori ethnicity (odds ratio [OR] 2.12 [95% CI 1.19-3.80], P = 0.011), household crowding (OR 1.19 [95% CI 1.02-1.39], P = 0.024) and lower socioeconomic status (OR 1.13 [95% CI 1.00-1.27], P = 0.048). There was no statistically significant association between FI and number of comorbidities or the primary reason for ED attendance. Of participants who were food insecure, only half reported being aware of (n = 56/111, 50.5%) or had used (n = 60/111, 54.1%) food resources. Participants who were food insecure were more likely to have utilised resources, either currently or in the past (OR 8.50 [95% CI 4.46-16.18], P < 0.001). Forty (13.3%) participants requested SW follow up and of those, most (n = 31/40, 77.5%) were successfully contacted. FI was associated with interest in SW follow up (OR 16.95 [95% CI 5.81-49.42], P < 0.001). At follow up, the majority (n = 24/31, 77.4%) of participants requested further information regarding food resources. FI was prevalent among patients in a regional NZ ED. An ED-based FI screening programme with voluntary SW follow up was feasible and acceptable to ED patients.

Emergency Department Demand and the First Year of the COVID-19 Pandemic.

We present a retrospective analysis of Emergency Department daily patient flow across 84 hospitals in Queensland, Australia over a four-year period from 2017 - 2020, leading up to and including the start of the COVID-19 pandemic. Daily ED demand significantly increased year-on-year over the study period, though significant increases in 2020 were likely attributed to ED fever screening clinics. Compliance against a four-hour ED Length of Stay target had been slightly decreasing since 2017, and the first year of the pandemic showed significant improvements in target compliance compared to previous years for all patients including the cohort admitted from ED. The length of stay for ED patients was also significantly less in 2020 (mean = 3.1 hours) compared to previous years. As an area of topical interest, a special focus on influenza-like illness presentations to ED helps quantify changes in volume of this cohort. This knowledge assists hospitals in planning and responding to variations in hospital demand.

Balanced crystalloids (RInger’s lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial

BackgroundCurrent diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study’s objective...