ED Presentations Research Articles

Planning for the future: Modelling daily emergency department presentations in an Australian capital city.

To describe and model a decade of ED presentations in metropolitan Melbourne, Australia, from July 2000 to June 2010 and to validate the model of ED presentations by testing the model's performance in forecasting the subsequent 2 year period of daily presentations, from July 2010 to June 2012. Retrospective analyses of prospectively collected data sourced from the Victorian Emergency Minimum Dataset were performed and included 13 public hospitals. Time series modelling involved unobserved components modelling and forward selection of variables using incidence rate ratios. Forecasting with the model and validation were performed using the 2 year period up to June 2012. Model performance was calculated using the mean average percentage error. A total of 7 031 242 patient presentations occurred to the sample metropolitan EDs in the 12 year study period. An absolute increase in mean daily ED presentations of 81.3% was observed. Presentations increased on Sunday and Monday incidence rate ratio of 1.10 (95% CI 1.08-1.11, P < 0.05). No monthly or seasonal pattern was evident. Public holidays were associated with increased presentations, incidence rate ratio of 1.11 (95% CI 1.08-1.15, P < 0.05). The model with the best goodness-of-fit and Wald χ2 value included Sunday-Monday (vs Tuesday-Saturday), public holidays, the trend of gradual increase over time and a stochastic (random white noise) cycle. The mean average percentage error for the 2 year forecast period was 3.6%. We have produced and validated a model for predicting daily ED presentations across a major city. Even though ED presentations are multifactorial, city-wide daily presentations are predictable and explained by a small number of variables. The model will have implications for future health planning.

Description and cost-analysis of emergency department attendances for hand and wrist injuries.

Injuries to the hand and wrist are estimated to account for between 10% and 30% of all ED presentations. The economic burden placed on the healthcare system can be extensive and rise sharply with increase in injury severity. This cost-analysis was performed with the aim of estimating the economic implications of ED attendances for hand and wrist injuries from the perspective of one Australian public health network. Data from two EDs were retrieved from the electronic billing records of one large health network across two financial year periods (2014-2015 and 2015-2016) using ICD-10 codes. All costs that resulted from the treatment of any acute hand or wrist injury across the 2 year period were calculated and are presented by age, sex, injury type and mechanism of injury. A total of 10 024 individuals presented to the two EDs in the 2 year period, accounting for approximately 5.4% of all presentations. The most common presentations were males (62.2%), people aged 25-34 years (26.9%) and lacerations (31.2%). The total cost in the 2 year study period was $3 959 535.38 ($1 923 852.38 in 2014-2015; $2 035 683.00 in 2015-2016). The mean cost per presentation was $383 (95% CI [$373, $393]) in 2014-2015 and $407 (95% CI [$394, $421]) in 2015-2016. Acute hand and wrist injuries contribute to a significant volume of ED presentations each year in one Australian public health network leading to significant expenditure and health resources. Further research into how to best utilise resources and reduce avoidable injuries should be priority areas to reduce the cost of these injuries to the healthcare system and society.

Burden of primary care-type emergency department presentations using clinical assessment by general practitioners: A cross-sectional study.

To compare methods of assessment of the burden of primary care-type ED (PCTED) presentations against clinical assessment by general practitioners (GPs) in ED. A cross-sectional study involving clinical assessment of patients presenting to four EDs in Western Australia. The GPs assessed patients who were likely to be discharged home from ED, and considered whether they could be managed in general practice. Patient presentations were defined by the GPs as: PCTED; PCTED if additional primary care resources were available; or not PCTED. GP researchers determined that 80% of patients assessed were PCTED presentations, with one-third of these considered PCTED presentations if additional resources were available. A high proportion of identified PCTED presentations included categories excluded by previous methods. Analysis of linked data found the cohort assessed to be of lower urgency, younger, and with a shorter length of stay than the average patient being discharged from ED. After accounting for potential bias, it is suggested that 20-40% of all ED presentations could be PCTED presentations. Previous methods determining the burden of PCTED presentations have not been validated. Many presentations excluded by previous methods were identified as manageable in general practice by GPs clinically assessing patients in ED. Improved validation of criteria used to identify PCTED presentations will enable appropriately designed interventions to reduce such events.

Clinical spectrum of previously undiagnosed pediatric cardiac disease

Previously undiagnosed pediatric cardiac disease represents a clinical challenge for the emergency physician. The clinical presentation of these disorders can mimic other conditions of the respiratory, gastrointestinal and neurologic systems at a time when the need for early identification and treatment is at a premium. A high index of suspicion and superb clinical acumen is required to make a timely diagnosis and initiate optimal care. MethodsA retrospective chart review using explicit criteria and a structured data collection process was performed on all children presenting with previously undiagnosed cardiac disease over a five and half year period. ResultsThirty-six patients were identified over a five and a half year period representing one patient per 4838 pediatric ED presentations. A diverse set of chief complaints, triage categories, clinical presentations and diagnoses were identified. Undiagnosed congenital lesions, acquired cardiac disease, dysrhythmias and infectious diseases of the heart were represented. The need for surgical intervention (22%) and mortality (6%) was substantial. ConclusionIn the aggregate, these conditions occur at an important rate and represent a high risk subset of pediatric patients presenting to the emergency department. Individually, the conditions occur infrequently and ‘pattern recognition’ may not aid the clinician. Early diagnosis and prompt intervention is important in this population.

Cytokines and Chemokines in Pediatric Appendicitis: A Multiplex Analysis of Inflammatory Protein Mediators.

Objectives We aimed to demonstrate the potential of precision medicine to describe the inflammatory landscape present in children with suspected appendicitis. Our primary objective was to determine levels of seven inflammatory protein mediators previously associated with intra-abdominal inflammation (C-reactive protein—CRP, procalcitonin—PCT, interleukin-6 (IL), IL-8, IL-10, monocyte chemoattractant protein-1—MCP-1, and serum amyloid A—SAA) in a cohort of children with suspected appendicitis. Subsequently, using a multiplex proteomics approach, we examined an expansive array of novel candidate cytokine and chemokines within this population. Methods We performed a secondary analysis of targeted proteomics data from Alberta Sepsis Network studies. Plasma mediator levels, analyzed by Luminex multiplex assays, were evaluated in children aged 5-17 years with nonappendicitis abdominal pain (NAAP), acute appendicitis (AA), and nonappendicitis sepsis (NAS). We used multivariate regression analysis to evaluate the seven target proteins, followed by decision tree and heat mapping analyses for all proteins evaluated. Results 185 children were included: 83 with NAAP, 79 AA, and 23 NAS. Plasma levels of IL-6, CRP, MCP-1, PCT, and SAA were significantly different in children with AA compared to those with NAAP (p < 0.001). Expansive proteomic analysis demonstrated 6 patterns in inflammatory mediator profiles based on severity of illness. A decision tree incorporating the proteins CRP, ferritin, SAA, regulated on activation normal T-cell expressed and secreted (RANTES), monokine induced by gamma interferon (MIG), and PCT demonstrated excellent specificity (0.920) and negative predictive value (0.882) for children with appendicitis. Conclusions Multiplex proteomic analyses described the inflammatory landscape of children presenting to the ED with suspected appendicitis. We have demonstrated the feasibility of this approach to identify potential novel candidate cytokines/chemokine patterns associated with a specific illness (appendicitis) amongst those with a broad ED presentation (abdominal pain). This approach can be modelled for future research initiatives in pediatric emergency medicine.

Analysis of patient related violence in a regional emergency department in Victoria, Australia

BackgroundEmergency Departments (ED) have been identified as high-risk areas for patient related violence (PRV). The aim of the present study was to analyse recorded events of violence in a regional Victorian hospital ED, and examine the association these events had with substance abuse. MethodsA retrospective cohort study was undertaken to establish the incidence of PRV. Data were obtained from the hospital's incident management system, RiskMan, over a five and a half year period for all violent events categorised as Code Grey (CG) and Code Black (CB). The Haddon Matrix attached to the individual incident record was also reviewed. ResultsA total of 548 violent events were analysed. The incident rate was 3.4 per 1000 ED presentations. Intoxication was the primary reason for violent escalations. There was no association between the frequency of CG events and the day of the week, month of admission, or shift of the day. Intoxicated men (110, 64.3%) were more likely to be the instigator of a violent event compared with intoxicated females (61, 35.7%) (OR 1.5, 95% CI: 1.19–2.02, p<0.001). A form of restraint, chemical, physical or both, was used in the majority of violent events (376, 68.6%). ConclusionThis study demonstrated an increasing frequency of violent events in the regional ED. Rates of PRV were comparable to those reported in metropolitan hospitals. Intoxication was the most frequently observed underlying factor for PRV. Regional hospitals are in need of additional resources to instigate policies and procedures that will maximise patient and staff safety.

Assessment of Acute Pain Management and Associated Factors among Emergency Surgical Patients in Gondar University Specialized Hospital Emergency Department, Northwest Ethiopia, 2018: Institutional Based Cross-Sectional Study.

Background Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients. Patients and Methods After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department. Results A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery. Conclusion The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice.

Drug overdose in the ED: a record linkage study examining emergency department ICD-10 coding practices in a cohort of people who inject drugs

BackgroundDrug overdose is a leading cause of mortality and morbidity amongst people who inject drugs (PWID). Drug overdose surveillance typically relies on the International Classification of Diseases (ICD-10) coding system, however its real world utilisation and the implications for surveillance have not been well characterised. This study examines the patterns of ICD-10 coding pertaining to drug overdoses within emergency departments for a cohort of known PWID.MethodsCohort data from 688 PWID was linked to statewide emergency department administrative data between January 2008 and June 2013. ICD-10 diagnostic codes pertaining to poisonings by drugs, medicaments and biological substances (T-codes T36-T50) as well as mental and behavioural disorders due to psychoactive substance use (F-codes F10-F19) were examined.ResultsThere were 449 unique ED presentations with T or F code mentions contributed by 168 individuals. Nearly half of the T and F codes used were non-specific and did not identify either a drug class (n = 160, 36%) or clinical reaction (n = 46, 10%) and 8% represented withdrawal states. T and F codes could therefore be used to reasonably infer an illicit drug overdose in only 42% (n = 188) of cases. Majority of presentations with T or F overdose codes recorded only one diagnostic code per encounter (83%) and representing multiple-drug overdose (F19.- = 18%) or unidentified substances (T50.9 = 17%) using a single, broad diagnostic code was common.ConclusionsReliance on diagnoses alone when examining ED data will likely significantly underestimate incidence of specific drug overdose due to frequent use of non-specific ICD-10 codes and the use of single diagnostic codes to represent polysubstance overdose. Measures to improve coding specificity should be considered and further work is needed to determine the best way to use ED data in overdose surveillance.

Morbidity burden and community-based palliative care are associated with rates of hospital use by people with schizophrenia in the last year of life: A population-based matched cohort study.

ObjectivePeople with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden.MethodA population-based retrospective matched cohort study of people who died from 01/01/2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated.ResultsOf the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care.ConclusionIn the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male. Community-based specialist palliative care was associated with increased rates of hospital admissions.

Management of abnormal observations in the emergency department: A review.

To assess utility and accuracy of general observation modified early warning score charts; and compare sensitivity and specificity of single- and multiple-parameter-based trigger scores on patient outcomes in the ED. Retrospective cohort clinical audit of all adult Modified Early Warning Score charts in the ED of a mixed tertiary hospital over 4 weeks. Data extracted included recorded parameters required to calculate Modified Early Warning Score and evidence of response. Of 5901 ED presentations, medical records system identified 2482 Modified Early Warning Score; 347 were missing or blank. Of 2135 Modified Early Warning Score charts, 19.5% contained a calculation error, 51.9% had one or more missing parameters and 36.6% did not have usual/target systolic blood pressure recorded; with 25.1% (95% confidence interval [CI] 23.3-27.0) charts correctly completed. Four hundred and forty-three had a single-abnormal parameter of which chart review showed 96.6% (94.5-97.3) were identified as abnormal by nurses with 25.7% (21.9-30.0); only 5.6% (3.9-8.2) had evidence of recognition by medical staff. Modified Early Warning Score sensitivity and specificity for ward admission was 14.7% and 96.1%, respectively. Modelling using the dataset of a single-abnormal parameter suggested sensitivity and specificity of 31.6% and 85.8%, respectively. This study highlights serious deficiencies in documentation of abnormal parameters and emergency response. It has also shown poor accuracy of both single- and multiple-parameter-based trigger scores in predicting patient outcomes within the ED. However, single-parameter-based trigger scores are twice as sensitive as total Modified Early Warning Score for admission and reduces documentation error by 23%.

The impact of unintentional alcohol-related falls on emergency departments

BackgroundAlcohol is the cause of many injury presentations to the emergency department. There has been little research on alcohol-related falls in the broader adult population, which represent a substantial proportion of the total alcohol-related injury presentations to emergency departments. MethodsA population-based retrospective analysis of public hospital emergency department presentations for Victoria for 2003–2015 was undertaken. ResultsAlcohol-related fall presentations have increased by 96% over the 13-year period, a rate of growth exceeding non-alcohol-related falls, all ED presentations, and Victorian population growth. Alcohol-related fall presentations are most prevalent in the 20–24 year age group, and among males. The severity of alcohol-related fall presentations is greater than non-alcohol-related fall presentations, based on triage scale ratings and admission rates, with head injuries being the most frequent type of injury. ConclusionsPublic health warnings about the risks of alcohol-related fall injuries and the need to seek medical treatment for head injuries in particular are necessary to raise awareness among younger people. Emergency staff vigilance with neurological assessments is needed for early diagnosis of traumatic brain injury in alcohol-related fall presentations to help prevent adverse outcomes.

Impact of emergency department occupancy on waiting times, rates of admission and representation, and length of stay when hospitalised: A data linkage study

To assess the association between ED occupancy and relevant outcomes including ED waiting times, rates of admission and representation and length of stay when hospitalised. Retrospective study of all ED presentations by New South Wales (NSW), Australia, residents to 15 NSW public, principal referral or paediatric specialist hospitals between 1 January to 31 December 2015 (N = 935 282). ED data were linked longitudinally (to ED data) and cross-sectionally to hospital admissions data. An ED-system measure of occupancy was assigned to each ED record. The study outcomes were ED waiting time, admission to hospital, 28 day representation, and length of stay (LOS) when admitted. Outcomes were analysed using univariate analyses and multivariable general linear and binary logistic regression models. Increased ED occupancy was associated with increased ED waiting times, particularly at low-baseline occupancy (e.g. rate ratio = 2.22, 95% confidence interval [CI] [2.10-2.35], for non-urgent triaged patients). However, results were conditional on triage category, such that estimated effects were smaller or not significant in emergency and resuscitation triaged patients (e.g. rate ratio = 1.59, 95% CI [1.52-1.65], for emergency patients). ED occupancy only showed small or no associations with admission to hospital, 28 day representation and LOS when admitted. Higher ED occupancy was associated with increased waiting times conditional on triage category and baseline occupancy. Collectively, the results show that NSW principal referral EDs are robust, and are currently capable of handling variation in occupancy by prioritising treatment for the most urgent patients.

Incidence of emergency department presentations for traumatic brain injury in Indigenous and non-Indigenous residents aged 15\u201364 over the 9-year period 2007\u20132015 in North Queensland, Australia

BackgroundTraumatic brain injury (TBI) is a leading cause of disability worldwide. Previous studies have shown that males have a higher incidence than females, and Indigenous populations have a higher rate than non-Indigenous. To date, no study has compared the incidence rate of TBI between Indigenous and non-Indigenous Australians for any cause. Here we add to this rather sparse literature.MethodsRetrospective analysis of data from North Queensland Emergency Departments between 2007 and 2015 using Australian Bureau of Statistics population estimates for North Queensland residents aged 15–64 years as denominator data. Outcome measures include incidence rate ratios (IRR) for TBI presentations by Indigenous status, age, sex, year of presentation, remoteness, and socio-economic indicator.ResultsOverall incidence of TBI presentations per 100,000 population was 97.8. Indigenous people had an incidence of 166.4 compared to an incidence in the non-Indigenous population of 86.3, providing an IRR of 1.93 (95% CI 1.77–2.10; p < 0.001). Males were 2.29 (95% CI 2.12–2.48; p < 0.001) times more likely to present than females. Incidence increased with year of presentation only in the Indigenous male population.ConclusionsThe greater burden of ED presentations for TBI in the Indigenous compared with the non-Indigenous population is of concern. Importantly, the need to provide quality services and support to people living with TBI in remote and very remote areas, and the major role of the new National Disability Insurance Scheme is discussed.

CancerCostMod: a model of the healthcare expenditure, patient resource use, and patient co-payment costs for Australian cancer patients

Although cancer survival in general has improved in Australia over the past 30 years, Indigenous Australians, socioeconomically disadvantaged persons, and people living in remote areas still experience poorer health outcomes. This paper aims to describe the development of CancerCostMod, and to present the healthcare expenditure and patient co-payments for the first 12-months post-diagnosis. The base population is a census of all cancer diagnoses (excluding non-melanoma skin cancer) in Queensland, Australia between 1 July 2011 and 30 June 2012 (N = 25,553). Each individual record was linked to their Queensland Health Admitted Patient Data Collection, Emergency Department Information System, Medicare Benefits Schedule, and Pharmaceutical Benefits Scheme records from 1 July 2011 to 30 June 2015. Indigenous status was recorded for 87% of participants in our base population. Multiple imputation was used to assign Indigenous status to records where Indigenous status was missing. This base population was then weighted, using a programmed SAS macro (GREGWT) to be representative of the Australian population. We adopted a national healthcare perspective to estimate the cost of cancer for hospital episodes, ED presentations, primary healthcare, and prescription pharmaceuticals. We also adopted an individual perspective, to estimate the primary healthcare and prescription pharmaceutical patient co-payments. Once weighted, our sample represents approximately 123,900 Australians (1.7% Indigenous Australians). The total healthcare system cost of all cancers during the first 12-months post diagnosis was $4.3 billion, and patient co-payments costs were $127 million. After adjusting for sex, age at diagnosis, Indigenous status, rurality, socioeconomic status, and broad cancer type, significant differences in costs were observed for population groups of interest within the first year post-diagnosis. This paper provides a more recent national estimate of the cost of cancer, and addresses current research gaps by highlighting the distribution of healthcare and individual costs by Indigenous status, rurality, and socioeconomic status.

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy

PurposeEmergency department(ED) visits after ureteroscopy(URS) are costly and inconvenient. To better understand those at risk, we aim to identify patient demographic, medical and surgical factors associated with 30-day ED presentation following URS for urolithiasis with particular attention paid to those with a history of a psychiatric diagnosis(PD). Materials and MethodsWe retrospectively reviewed 1576 cases on 1395 adults who underwent stone-related URS over 3 years at two hospitals. We collected patient demographics, medical history, and operative details. The primary outcome was return to ED within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with ED presentation. Results613(43.9%) patients had a history of PD. 12.6% of URS encounters returned to the ED within 30 days of their ureteroscopy procedure. Of those, 58.8% had a history of PD. On multivariable analysis, variables associated with ED return included: history of PD(OR 1.57,p=0.012), uninsured status(OR 2.46,p=0.001), and stone only in the kidney(OR 1.76,p=0.022). Patients who returned to the ED had more ED visits in the year prior to surgery(OR 1.40,p<0.001). On univariable analysis, older patients and those with longer OR times were more frequently admitted from the ED(OR 1.03,p=0.002; OR 1.96,p=0.03 respectively) while uninsured patients were admitted less frequently(OR 0.19,p=0.013). No difference in admissions between those with a PD and all others(60.7% vs 55.8%;p=0.48). ConclusionsWe identified factors associated with ED return after ureteroscopy, including history of PD, uninsured status, and ED visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary ED visits.

Presentations to the emergency department with non-medical use of benzodiazepines and Z-drugs: profiling and relation to sales data.

Non-medical use of benzodiazepines and Z-drugs is common; however, there is limited information available on the extent of harm related to this in Europe, as well as the relationship between misuse and availability. To describe presentations to the emergency department in Europe related to the recreational use of benzodiazepines and Z-drugs and compare regional differences in these presentations with legal drug sales of benzodiazepines and Z-drugs within each country. Emergency department presentations with recreational misuse of benzodiazepines and Z-drugs were obtained from the Euro-DEN dataset for the period from October 2013 to September 2015; data extracted included demographics, clinical features, reported coused drugs, and outcome data. Sales figures obtained by QuintilesIMS™ (Atlanta, Georgia) were used to compare regional differences in the proportion of benzodiazepines and Z-drugs in the emergency department presentations and legal drug sales across Europe. Over the 2years, there were 2119 presentations to the Euro-DEN project associated with recreational use of benzodiazepines and/or Z-drugs (19.3% of all Euro-DEN presentations). Presentations with 25 different benzodiazepines and Z-drugs were registered in all countries, most (1809/2340 registered benzodiazepines and Z-drugs, 77.3%) of which were prescription drugs. In 24.9%, the benzodiazepine was not specified. Where the benzodiazepine/Z-drug was known, the most frequently used benzodiazepines and Z-drugs were respectively clonazepam (29.5% of presentations), diazepam (19.9%), alprazolam (11.7%), and zopiclone (9.4%). The proportions of types of benzodiazepines/Z-drugs related to ED-presentations varied between countries. There was a moderate (Spain, UK, Switzerland) to high (France, Ireland, Norway) positive correlation between ED presentations and sales data (Spearman Row's correlation 0.66-0.80, p < 0.005), with higher correlation in countries with higher ED presentation rates. Presentations to the emergency department associated with the non-medical use of benzodiazepines and/or Z-drugs are common, with variation in the benzodiazepines and/or Z-drugs between countries. There was a moderate to high correlation with sales data, with higher correlation in countries with higher ED presentation rates. However, this is not the only explanation for the variation in non-medical use and in the harm associated with the non-medical use of benzodiazepines/Z-drugs.

40EMF Outpatient Lisinopril and Losartan Blood Levels Are Associated With In-Hospital Acute Kidney Injury Among Patients With Acute Heart Failure

We report a novel tandem liquid chromatography mass spectrometry (LC/MS/MS) method for the simultaneous bioanalytical assessment of blood levels for multiple commonly prescribed medications, including angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Despite morbidity and mortality benefits of ACEI/ARBs, these medications may cause a transient rise in creatinine and occasionally contribute to hypotension, which in turn may result in acute kidney injury (AKI). Previous studies of AKI in the setting of ACEI/ARBs have not assessed medication levels. We hypothesized ACEI/ARB plasma levels in/above reference range for patients with AHF treated by intravenous (IV) diuretics would be associated with increased risk of in-hospital AKI compared to undetectable/low ACEI/ARB plasma levels. From June 2016 to June 2017, adults with AHF were approached for consent. Exclusions were: 1) no outpatient ACEI/ARB, 2) systolic blood pressure <90 mm Hg, 3) IV diuretic before enrollment, 4) allergy to furosemide or bumetanide, or 5) any dialysis. Patients were given an initial IV dose of diuretic (2x their daily dose) and received standard clinical care during hospitalization. Medication plasma levels at ED presentation, before AHF therapy, were assessed using LC/MS/MS. Standardized plasma concentrations for each medication were computed using the median published reference range. AKI was defined as a rise in creatinine at 48 hours (or at hospital discharge, if unavailable) of ≥0.3 mg/dL or ≥1.5x baseline. Mean age for the 37 patients was 65.9 years (sd 14.6), 20 (54.0%) were female, 11 (29.7%) were African American, 10 (32.3%) had an ejection fraction <40%, and 11 (29.8%) did not have detectible ACEI/ARB levels. Of the 5 (13.5%) patients who developed in-hospital AKI, 4 had medications in/above reference range. ACEI/ARB levels were higher for patients with AKI (Figure), and levels in/above reference range were associated with a rise in creatinine (beta 0.22, 95% confidence interval 0.02-0.42, P=0.03, adjusted for age, sex, and race). Patients with AHF may be more likely to develop AKI in the hospital if they have normal/high ACEI/ARB blood levels at ED presentation. Bioanalytical assessment of ACEI/ARB levels may prove useful for guiding in-hospital medical therapy for AHF.

278 Opioid Pill Consumption After an Emergency Department Visit: How Many Pills Are People Using?

Recently published guidelines advise limiting opioids prescriptions for acute painful episodes to a 3-day supply; however, there is little literature available to quantify patterns of opioid use after an ED visit. Additionally, the number of pills included in a 3-day supply is not quantified in guidelines and may vary widely (eg, a 3-day supply of hydrocodone-acetaminophen using typical dosing intervals could be 12 tabs (1 PO Q6 hours) or 36 tabs (2 PO Q4 hours)). We sought to describe opioid consumption patterns after an ED visit for acute pain and quantify the proportion of patients who would exceed a 3-day supply at the commonly dispensed quantity of 12 tabs. As part of a larger interventional study promoting the safe use of opioids after an ED visit to an urban academic hospital (>88,000 visits), patients completed a 10-day medication diary documenting their medication consumption (including both analgesics and other home medications). Patients were enrolled if they were age >17 years, received a prescription for hydrocodone-acetaminophen and did not chronically use opioids. Patients were included in this analysis if they returned the completed medication diary and had a discharge diagnosis in 1 of 4 categories: back pain, kidney stone, fracture or musculoskeletal injury (non-fracture). Patient demographics and pain scores are reported. Opioid consumption is described using daily number of pills consumed and daily morphine milligram equivalents (MMEs) both for the sample overall and by diagnosis group. Additionally the proportion of patients continuing opioid use is reported by post-visit-day both overall and by diagnosis. 191 patients with the diagnoses listed above returned completed medication diaries [45 (24%) back pain, 52 kidney stone (27%), 54 fracture (28%), 40 (21%) musculoskeletal injury (non fracture)]. Mean Age a 6 years (sd 14), 57% female. Pain scores on ED presentation were high and remained high post discharge (eg, Day 1: 7 (N=161), Day 2: 7 (N=143), Day 3: 6 (N=122)). Mean quantity of opioid pills prescribed: 16 tabs. On the day of discharge (Day 1), 85% of patients consumed an opioid at home (87% back pain, 73% kidney stone, 93% fracture, 88% musculoskeletal injury) with a mean tabs consumed of 1.7 (sd 1), resulting in 11.2 (7.9) MME (13.9 (11.4) MME back pain, 9.5 (5.2) MME kidney stone, 10.7 (6.9) MME fracture, 11.1 (6.6) MME musculoskeletal injury). The proportion of patients consuming opioids on subsequent days decreased on the day after discharge for patients with kidney stones (42%) and fractures (81%), remained stable for those with musculoskeletal pain (90%) and increased for those with back pain (91%). Among those patients taking pills on the first 2 days after discharge (Day 2 and Day 3) the MME consumed increased (15 (10.2) and 15.6 (12.2) MME, respectively) before decreasing on subsequent days (Day 4: 13.5 (11.5) MME, Day 5 13.3 (9.2) MME). Only 7.7% of kidney stone patients consumed more than 12 pills; whereas 42.2% of back pain patients consumed more than 12 pills in the 10 days post-discharge. 81% of patients had leftover pills (66% back pain, 96% kidney stones, 74% fracture, 87% musculoskeletal injury). In this sample, pill consumption varied by illness category; however, overall patients were consuming low quantities of pills and the majority had unused pills 10-days after their ED visit. Further data could help support prescribing tailored by diagnosis and minimize unused pills.

300 The Effect of Reviewing Health Information Exchange Data on Emergency Department Care Times and Imaging

Establishing interoperability through health information exchange (HIE) is expected to reduce health care costs and improve quality of care. These benefits are presumed to be associated with reductions in repeat testing and reduced rates of admission. Our institution utilizes Epic’s Care Everywhere, an HIE which functions on a combination of push and pull data exchanges with multiple neighboring institutions including 3 of the 4 regional academic institutions. When HIE data is available, an activity tab becomes viewable to the end user, but there are no prompts to review this information. We determined how frequently providers in our ED reviewed HIE data by activating this activity tab, and if the review of HIE data affected discharge length of stay (LOS), time to decision to admit (DTA), affected odds of discharge or reduced advanced imaging (CT, MRI, US). We examined results from 2 hospitals, 1 academic (AH) and 1 community (CH). We queried our electronic health record (EHR) for any patient presentation in the main ED, where any health care provider reviewed HIE data during a 1-year period from 4/1/17 to 4/30/18. We compared these results to those patients who did not have HIE data accessed. We excluded patients under 18 years, and lower acuity (ESI 4 and 5) patients. Times, dispositions, and rates of imaging orders were calculated for those patients with and without HIE information review. Results are presented as percent frequency of occurrence and 95% confidence intervals, with statistical analysis via Mann-Whitney test. There were 24,036 arrivals to CH and 29,843 arrivals to AH that met inclusion criteria. Of these 2,962 (12.3%) and 5,662 (18.9%) had HIE data accessed respectively. At both sites median LOS to discharge was longer for those with HIE data accessed: CH: 207.9 min (95% CI, 205.7 - 210.1) versus 225.3 min (217.0-241.4), p<0.001, and AH: 272.6 min (269.9-275.3) versus 300.7 min (292.5-309.9), p<0.001. DTA was longer when HIE data was accessed at AH (245.4 min [238.2 - 254.6] versus 234.4 min [230.3-240.3], p<0.001) but not different at CH (184.6 min [95% CI 179.9-191.8] versus 187.6 min [95% CI 183.3-191.5], p=0.5). Odds of discharge versus admission or observation were lower in those patients with HIE data accessed at both sites (CH 0.17 [95% CI 0.16-0.19] versus AH 0.28 [95% CI 0.26-0.3]). There were increased odds of receiving an imaging study for those without HIE at CH (1.3 [95% CI 1.2-1.4]) but not at AH (0.96 [95% CI 0.9-1.02]). Review of HIE information did not result in reducing ED care times, but at CH HIE review resulted in a decrease in odds of receiving an advanced image. Many factors may influence an ED provider to review HIE data, including the acuity and clinical condition of a patient. These characteristics may have biased our results, resulting in our finding of longer or unchanged ED care times for those patients with HIE review. Further research could examine more granular potential benefits of HIE use, when and how HIE influences medical imaging and explore ways to increase rates of HIE data review to determine if it is possible to attain the proposed benefits of this technology.

189 Chest Radiograph Utilization in Children With Mild-Moderate Asthma: Effect of Clinical Guidelines and Does Emergency Department Volume Matter?

Asthma is one of the most common conditions seen in the pediatric population with > 600,000 ED visits/year for acute asthma exacerbations. Studies have demonstrated that chest radiograph (CXR) is the most frequently ordered ancillary test in exacerbations, despite the fact that no recommendations support this. Even in the setting of fever, hypoxia, or crackles, CXR does not change management, and should only be limited to patients who either do not improve after bronchodilator therapy or were started on antibiotics within a week of ED presentation. Children with asthma frequently have some degree of consolidation due to secretions and airway obstruction and this can mistakenly be read as pneumonia, resulting in unnecessary antibiotic usage. Rolling out standardized asthma guidelines has been shown to improve asthma care and decrease CXR utilization. Based off of this information we hypothesized that introduction of standard asthma practice guidelines throughout our multi-center hospital system would decrease CXR utilization in the ED. Study data was abstracted from November 2015 to November 2017 from the electronic medical record (EMR) for patients aged 0-18 seen in 12 EDs both pediatric-specific and general EDs (adults and children) with an ED discharge diagnosis of mild to moderate asthma defined as a primary discharge diagnosis of asthma or wheeze discharged from the ED (mild to moderate asthma). The following variables were extracted: age groups <1 yr., 1-4 yrs., 5-9 yrs. 10-14 yrs., 15-17 yrs. and >17, sex, and receipt of a CXR in the pediatric-specific and general EDs were stratified by pediatric volume low 1-1799, medium 1800-4999, medium-high 5000-9999, high >10,000. Descriptive statistics were used to assess differences in CXR utilization prior to and after the publication of a standardized asthma guideline (November 2016). There were 4398 mild-to-moderate asthma visits included from 8 hospitals (after exclusion of 4 hospitals with a total of 418 visits that we did not have pre-data). The CXR performance per age groups: <1 yr. (29.8%), 1-4 yrs. (27.4%), 5-9 yrs. (23.8%), 10-14 yrs. (22.9%), 15-17 yrs. (32.8%) and >17 (39.9%); 59% males; 75% not Hispanic or Latino. The CXR performance pre- and post-guidelines was as follows: 1 pediatric-specific ED 21.8% versus 20.96%; 1 high volume ED 41% versus 42.9%; 2 medium-high volume ED 32.7% versus 31.74%; 3 medium volume ED 36.8 % versus 37.69%; and 1 low volume ED 38.2% versus 36.84%. Judicious use of CXR is noted to limit radiation and incidental findings, improve patient safety, and reduce costs. The pediatric-specific ED performed a significantly lower percentage of CXR in mild to moderate asthma patients discharged from the ED as compared to general EDs. Implementation of a system wide asthma policy did not show a significant decrease in CXR utilization across all EDs. Further education of clinicians and embedding asthma guidelines in a standard workflow are necessary to continue to decrease unnecessary CXR usage.