ED Sites Research Articles

The ball's in your court: Trends, causes, outcomes, and costs of patient transfer for pediatric testicular torsion

BackgroundThe transfer of pediatric patients with testicular torsion from community hospitals to pediatric centers can be a time and resource-intensive step toward emergent surgical intervention. ObjectiveWe sought to describe trends of patient transfer in our state and compare clinical outcomes and health system costs between patients transferred and treated primarily at a pediatric center. Study DesignThis retrospective cohort study compared patients aged 1-18 years who presented directly to a pediatric center to those transferred for acute testicular torsion from 2018-2023. Exclusion criteria included age <1 year, non-urgent surgery, and admission from clinic. Patient age, BMI, Tanner stage, ASA class, insurance coverage, and presentation time were covariates. Group characteristics and times from symptom onset to initial ED presentation to surgery were compared via two-sided Student’s t-tests. Clinical outcomes (orchiectomy, testicular atrophy) were compared via Fisher’s exact tests. Costs from transferring hospitals were estimated from costs at our institution, and medical transport costs were extrapolated from contract prices between transport agencies and the pediatric center to compare total episode-of-care cost. ResultsA total of 133 cases (37 primaries, 96 transfers) met inclusion criteria. Transfers increased over the study period (67% to 75%). There were no significant differences in age, Tanner stage, ASA score, BMI, or time of day of presentation between groups. Median transfer distance was 12 miles (IQR 7-22) and time was 1 hour (IQR 1-2). More than half of cases (53%) were transferred due to hospital policy regarding surgical treatment of minors, and 25% due to lack of urology coverage. Time from initial ED site to OR was nearly doubled for the transfer group (median 4.5 vs 2.5 hours, p=0.02). Despite a higher rate of orchiectomy in the primary group (43 vs 22%, p=0.01), this difference was not significant after stratification by symptom duration. The estimated average cost of care for patients transferred was twice that of primary patients ($15,082 vs $6,898). DiscussionTransfer of pediatric patients in our state for testicular torsion has increased in recent years. Hospital policies and local urology coverage are primary drivers of patient transfer which nearly doubled time to surgical intervention and more than doubled cost of care. Clinical outcomes were driven by delayed presentation. ConclusionTransfer of pediatric patients for testicular torsion nearly doubles time to surgical intervention and more than doubles cost of care. Restrictive hospital policies and gaps in rural hospital urology coverage present opportunities to improve the quality and efficiency of care for these children.

A Jurchen Temple at the Southern Ussuri Fortifi ed Site, in Primorye

The article outlines the fi ndings of excavations of a ritual building discovered at the Southern Ussuri fortifi ed site (Primorye Territory), identifi ed as the capital of the Xupin county of the Jurchen Jin Dynasty. Previously it was thought that the Southern Ussuri town was founded by the Balhae people and that during its early period it was the center of the Balhae district of Shuaibin, while the Jurchens appeared there later. However, our fi ndings suggest that the town belonged to the Jurchens from the beginning. Despite the high density of modern buildings on the territory of the medieval town, our study of what was left of the habitation deposits has allowed us to determine the architectural horizons and to associate them with specifi c historical periods. Based on the analysis of materials excavated from a building located on the upper architectural horizon, architectural features of a medieval building representing the Buddhist tradition were described: the colonnade, roof style, and sculptural representations of dragons, phoenixes, and Buddhist immortals. New decorative motifs on the tiles of the front and eaves of the roof were discovered, and new standards of building materials were identifi ed. The fi ndings suggest that the ritual structure dates to the 13th century— the second period of the Jurchen Eastern Xia State (1234–1276), preceding the Yuan Dynasty. Special architectural features revealed during the excavations of the upper architectural horizon are reliable indicators for assessing the age of other sites in Primorye.

206 Development and Validation of a Simple Clinical Prediction Tool to Identify Individuals in the Emergency Department at High Risk of Posttraumatic Stress Disorder After Motor Vehicle Collision

Approximately 4 million individuals are seen in US EDs after motor vehicle collision (MVC) each year. The overwhelming majority (>90%) are discharged to home after evaluation. Posttraumatic stress disorder (PTSD) is a relatively common sequelae in this population, occurring in ∼15-30% of individuals discharged to home from the ED. No ED-based or ED-initiated secondary preventive interventions are routinely available to prevent PTSD among those at high risk. The development of such interventions has been hampered by the lack of a simple clinical prediction tool that can be used in the ED to risk stratify individuals for PTSD risk. We sought to develop and validate such a tool. ED patients 18-75 years old were recruited at 28 ED sites. Candidate predictive baseline characteristics assessed (n=265) spanned 11 risk factor domains, including sociodemographic characteristics, lifetime trauma, pre-trauma stressors and psychological distress, pre-trauma mental and physical health, MVC characteristics, peritraumatic symptoms, personality, and social support. PTSD was defined by a PCL-5 score ≥ 38 at 3-month follow-up. Inverse missing probability weighting was used to balance baseline characteristics with full cohort (eg, 20% without 3-month follow-up). Lasso logistic regression with nested binary variables for identified influential factors was used to develop the predictive tool in the derivation sample (19 ED sites in 13 states, n=1282). Application of tool in the validation sample (11 different ED sites in 6 states, n=286) was used to assess generalizability. In derivation and validation samples (n=1570, 68% female, 33% non-Hispanic White, mean age 36), 26% met criteria for 3-month PTSD. A simple 8-item tool had AUC=0.83 with excellent calibration in the derivation cohort, and AUC=0.76 with continued excellent calibration in the validation cohort. (The tool also had AUC=0.78 and excellent calibration in a separate non-MVC sample.) At thresholds of .3 and .4, the tool had sensitivity/specificity of 69%/80% and 58%/85%, respectively. The most important predictors were anxiety sensitivity, pre-MVC depressive and distress symptoms, and peritraumatic psychophysiological symptoms. A simple 8 question tool can be used in the ED to help identify those at high risk of PTSD. This tool may be useful in clinical trials testing secondary preventive interventions for PTSD.

144 Should Teachers Carry Guns in Schools? An Emergency Department Survey of Parents’ Opinion and Potential Solutions

The purpose of this study was to determine parents’ opinion of threats and probable solutions to school gun violence in two diverse populations. Parents of school-aged children visiting EDs of two large trauma centers in Upstate New York (UNY) and New York City (NYC), between January 2019 to December 2020, were surveyed. Questions included parental perceptions of school safety, experience with firearms, violence and probable solutions including arming school staff, and hiring security officers. Responses were compared by ED site, and by parents’ experience with firearms and concern for school safety employing t-tests and Chi-square tests. A total of 302 participants completed the survey, 202 from UNY and 100 from NYC. Respondents from NYC on average, were significantly younger by about 6 years (95% CI: 4.17, 7.80), and were primarily Latino (81%); whereas the majority of respondents at UNY were White (67.5%), more likely to be female (75% vs 60%), have more college education (25% vs 0%) and less likely to be residing in an urban location (25% vs 100%). Although 64% of all respondents feared a shooting incident could occur at their child’s school, UNY respondents were significantly less likely to report moderate to extreme concern (46.5% vs 99% respectively, p<0.001). This was also reflected in response to “how safe the parents felt for their children at school” with UNY respondents significantly more likely to report moderate to extreme safety as compared to NYC (75.3% vs 7%, p<0.001). UNY respondents were significantly more likely to report feeling safer if guns were available to teachers (22.3% vs 6%, p <0.001). Majority of the respondents at both sites agreed on the need for an armed police presence at school with a minimal difference by site (76.73% vs 74%, p=0.11). Overall, of the 193 participants who indicated they were concerned about a shooting at their child’s school, 25.7% indicated they would feel safer if guns were available to teachers in schools versus only 11.92% of participants who are not concerned (p=0.002). When provided with potential solutions to make schools safer, a majority of the respondents agreed that each choice would make schools safer. However, the degree of agreement differed by site. For each potential solution respondents from NYC were almost unanimously supportive as compared to UNY, whose support ranged from 52% for metal detectors to 84.5% for controlled entry points. Demographics, perception of child safety in schools, and reported experiences wpith guns vary significantly by location, but majority of parents agreed on potential solutions. Less than a quarter of parents would feel safer if teachers had guns in school. For those who feel safer with school staff carrying guns in school, the majority feel security officers should be the ones with firearms. About three-fourths of parents surveyed believed that armed police should be present in schools.

145 Characteristics and Three-Month Outcomes of Individuals Presenting to the Emergency Department after Physical Assault

More than 1.6 million individuals present to US EDs each year for care after physical assault. However, little is known about posttraumatic outcomes of this population. We assessed the incidence of adverse posttraumatic neuropsychiatric sequelae (APNS) in a prospective longitudinal sample of individuals presenting to the ED after physical assault. ED patients aged 18-75 who presented to one of 28 ED sites after physical assault were eligible for enrollment if they had no evidence of solid organ injury > grade 1, no significant hemorrhage, no indication for chest tube placement or operation under general anesthesia, and were unlikely to be admitted for more than 72 hours. Baseline assessments included sociodemographic characteristics, maximal AIS score, and characteristics of the assault. Three-month outcome assessments included assessment of substantial posttraumatic stress (PTS, PCL-5 ≥ 38), pain (numeric pain scale score ≥ 4), and depressive (PROMIS-8b depression ≥ 60) symptoms. Associations between patient characteristics and APNS were evaluated using logistic regression. A total of 271 patients were enrolled in the study following physical assault. The mean age was 33.5 (SD 11.7), and 48% were female. Most participants identified as non-Hispanic Black (64%), non-Hispanic White (21%), or Hispanic (11%). The majority n= 206 (76%) reported being attacked by another person, 46 (17%) reported starting or intentionally joining an altercation, and 19 (7%) reported another assault mechanism. Average maximal AIS score was 1.3 (range 1-3), 99% were discharged to home after evaluation. Three month follow-up results were available for 207/271 patients (76%). Substantial PTS symptoms 3 months after assault were present in 63/199 (32%), substantial pain was present in 107/206 (52%), and substantial depressive symptoms were present in 70/207 (34%). After controlling for age and sex, patients who were attacked had more severe PTS symptoms (b=0.18, t=2.40, p=0.018) and depressive symptoms (b=0.18, t=2.45, p=0.015) than those who reported intentionally joining an altercation, but not more severe pain symptoms (b=0.12, t=1.67, p = 0.097). In 60% of cases (n = 163/271) the assailant was unknown to the patient. After controlling for age and sex, individuals in an altercation with an unknown assailant did not report more severe PTS (b=0.005, t=0.06, p=0.949), pain (b=-0.11, t=-1.47, p=0.142), or depressive symptoms (b=-0.08, t= -1.05, p =0.292) than individuals in an altercation with a known assailant. Among patients treated in the ED after physical assault, even when injury severity is low APNS are common. Secondary preventive interventions are needed to reduce the incidence of PTS, pain, and depressive symptoms after physical assault. Funded by NIMH U01MH110925, the US Army Military Operational Medicine Research Program, The One Mind Foundation, and The Mayday Fund.

Sex-related differences in opioid administration in the emergency department: a population-based study

BackgroundSex differences in pain experience and expression may influence ED pain management. Our objective was to evaluate the effect of sex on ED opioid administration.MethodsWe conducted a multicentre population-based observational...

Predicting hospital admission for older emergency department patients: Insights from machine learning

BackgroundEmergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications. Materials and methodsWe analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation. ResultsGradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition. ConclusionTo the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.

MP33: Provincial spread of buprenorphine/naloxone initiation in emergency departments for opioid agonist treatment: a quality improvement initiative

Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures &amp; Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.

LO04: Decreasing emergency department length of stay for patients with acute atrial fibrillation and flutter: a cluster-randomized trial

Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P &lt; 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P &lt; 0.01), electrical cardioversion (45.1% vs 56.8%; P &lt; 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P &lt; 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P &lt; 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.

Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017-2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%-42.6%) for XR, 19.1% (IQR 11.4%-24.9%) for CT, and 0.09% (IQR 0%-0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%-61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%-81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: -12.7%, -4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: -7.3%, -1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: -5.9%, -0;5%), CT (20.1% vs 17.7%; 95% CI: -5.1%, -0.4%) or MRI (0.8% vs 0.7%, 95% CI: -0.4%, -0.3%). Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.

Consumer Attitudes Towards Accepting SNAP Benefits at Farmers’ Markets

ABSTRACT Farmers’ markets provide access to healthy, fresh fruits and vegetables. This study surveyed farmers’ market customers, SNAP and non-SNAP, regarding their opinions about SNAP EBT, debit, and credit cards as payment; offering double value incentives; and factors that influence SNAP participant shopping behaviors. A total of 160 surveys were analyzed. All SNAP participants and a majority of non-SNAP participants agreed that farmers’ markets should accept SNAP EBT and would continue to shop at markets that accepted SNAP EBT. Farmers’ markets that offer SNAP EBT and double value create potential to increase fruit and vegetable intake and decrease the burden of disease among low-income families. While there may be farmers’ markets accepting SNAP EBT and offering double value incentives to increase the purchasing power of SNAP participants. It is vital that farmers’ market managers partner with SNAP Ed sites and communities to promote the acceptance of SNAP EBT at the market so that the SNAP participants are made aware.

Emergency Medicine Palliative Care Access (EMPallA): protocol for a multicentre randomised controlled trial comparing the effectiveness of specialty outpatient versus nurse-led telephonic palliative care of older adults with advanced illness

IntroductionEmergency department (ED)-initiated palliative care has been shown to improve patient-centred outcomes in older adults with serious, life-limiting illnesses. However, the optimal modality for providing such interventions is unknown. This...

Identification of Potential Small Molecule Binding Pockets in p38α MAP Kinase.

Given the essential role played by protein kinases in regulating cellular pathways, their dysregulation can result in the onset and/or progression of various human diseases. Structural analysis of diverse protein kinases suggests that these proteins exhibit a remarkable plasticity that allows them to adopt distinct conformations in response to interactions with other proteins, providing an opportunity for designing allosteric modulators. The present work reports the results of an in silico screening study aimed at identifying novel prospective allosteric binding sites in the paradigmatic p38α MAP kinase. The process was carried out using a protein ensemble generated from a 6 μs accelerated molecular dynamics simulation. The results of this calculation were first used to study the flexibility of the protein using Principal Component Analysis, followed by a Cluster Analysis aimed at producing an ensemble of conformations representative of the sampling process. Representative structures of the diverse clusters were subsequently screened for hot spots using FTMAP. The procedure permitted the identification of diverse allosteric sites of p38α already described in the literature including the DFG pocket, the lipid binding pocket, the DEF site, the docking groove, the CD and ED sites, and the backside site as well as a novel site recently reported: the A-loop regulatory site. Furthermore, the study also permitted the identification of ten novel prospective allosteric sites named NP1 to NP10, involving in most of the cases protein structural elements that control kinase activation including the activation loop, the catalytic loop, the αC helix, the L16 loop, and the glycine-rich loop.

Starting my NP career in the bush

From RN to NP in rural health 1.Explore my journey as a rural RN, into a rural Emergency Department [ED] Nurse Practitioner [NP], employed to work in a GP led health service. This will be achieved through:•My personal reflection•Challenges faced•The positive impact of the NP position on staff and the community•Goals moving forward2.To inspire others in pursuing the NP career, and add to the discussion of promoting the NP role in healthcare services (N Jennings, Gardner, O’Reilly, & Mitra, 2015; Robins, Jamieson, Carroll, & Boreham-Downey, 2015) Personal opinion and reflection, with supported evidence (Bryson, 2016). Approval to use information and data from Western Australia Country Health Service [WACHS] obtained for this presentation (Mills, Lindsay, & Gardner, 2011; WACHS, 2010, 2015) 15 minute presentation Challenges working in rural setting, in GP led hospital. The rural ENP is not confined to Fast Track presentations (Natasha Jennings, 2013). Impact of having an ED specific practitioner in a rural hospital. 1.The transition from RN to NP is a challenge.2.The ED NP role is a vital role for rural and remote EDs.3.The ED NP is the vital link and support between rural and remote, GP clinics, and tertiary ED sites.

LO32: Are EMS offload delay patients at increased risk of adverse outcomes?

Introduction: ED and hospital overcrowding cause offload delays that remove EMS crews from service and compromise care delivery to patients. Prolonged ED boarding times are associated with increased hospital LOS and patient mortality, but the impact of offload delays has not been studied. Our objective was to determine whether offload delays are associated with adverse system and patient outcomes. Methods: From July 2013 to June 2016, administrative data was collated from four Calgary adult EDs. All CTAS 2 and 3 EMS arrivals were studied. Those assigned an ED care space within 15 minutes were considered controls while those with delays of ≥60-minutes were considered ‘delayed’. Multivariable logistic regression was used to determine propensity scores, which were used to match delayed patients to nearest neighbor controls. Matching variables for propensity modeling included age, sex, CTAS level, ED site, arrival day and time, living situation (homecare/facility vs. independent), complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other) and previous ED use (visits within 1 year). The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality. Results: A total of 111,743 patients were studied: 70711 controls and 41032 delayed (median time to stretcher of 8 vs. 109 minutes). There was significant baseline covariate imbalance: Delayed patients were more likely to be female, older, have lower CTAS acuity, arrive on weekdays and evenings, to have general medical complaints, and to arrive at the slowest offload site. In the unmatched analysis, delayed patients had lower 7-day mortality (2.1% vs. 2.6%), similar 30-day mortality (3.5% vs. 3.6%), and longer hospital LOS (10.3 vs. 9.8 days). In the propensity-matched analysis (41016 patients per group), covariate balance was substantially improved and outcomes differed slightly. Seven and 30-day mortality were essentially unchanged, but between group differences for hospital LOS disappeared (10.3 vs. 10.2 days). Conclusion: Propensity analysis suggests that EMS patients exposed to offload delays have similar 30-day mortality and slightly lower 7-day mortality than patients who receive timely ED access. While offload delays lead to substandard hallway care, patient dissatisfaction, and remove EMS crews from service, the levels of offload delay studied here were not associated with higher mortality or prolonged hospital LOS.

LO34: System and patient level determinants of EMS offload delay

Introduction: Arriving EMS patients often experience offload delay due to a lack of available care spaces. Arrival in an overcrowded ED is the primary cause of offload delay, but patient characteristics may also play a role. Our objective was to describe system and patient level determinants of offload delay. Methods: From July 2013 to June 2016, administrative data was collated from the four Calgary Zone adult EDs. All CTAS level 2 and 3 patients arriving by ambulance were eligible for study. To define patient complexity and illness severity, we captured patient demographic data, living situation (homecare/facility vs. independent), vital signs, complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other), biochemical parameters (serum Na, K, creatinine, hemoglobin, WBC), patient care needs (IV fluid bolus, IV antibiotics, CT scan, admission) and mortality at 7 and 30 days. Results: 162,002 EMS patients were studied. Of these, 67,785 went to a care space within 15 minutes (minimal offload delay), 53,185 between 15 and 59 minutes (moderate offload delay), and 41,032 at ≥60 minutes (severe offload delay). Vital signs, biochemical and hematologic parameters did not differ between groups. ED site was a strong predictor of offload delay (odds ratio {OR}=1.0, 2.03, 2.14, 3.5 for the 4 EDs), as was arrival on weekday (OR=1.38) or night shift (OR=0.71). After adjusting for site, day and time of arrival, multivariate logistic regression models showed the following associations with offload delays of more than 15 minutes: male sex (OR=0.94), age (OR=1.01 per year of age), dependent living situation (OR=1.15), CTAS 3 acuity (OR=1.27), number of prior ED visits within a year (OR=1.06 per visit), and complaint category: general medical (1.0), cardiovascular (0.90), mental health/neuro (0.90), GI (0.85), trauma/MS (0.61). Odds ratio estimates were precise—all with p&amp;lt;0.001. Offload delay was associated with prolonged time to MD, increased EDLOS and higher LWBS/AMA rates. Delayed patients had similar rates of IV antibiotic use, but lower rates of IV fluid bolus, CT use, admission, and 7-day mortality. Conclusion: The strongest predictor of offload delay is arrival to a crowded ED, but patient factors including female sex, older age, dependent living status and repeat hospital use increase risk. Patients subjected to offload delay also appear to have lesser immediate care needs and lower short-term mortality.

Medical expulsive therapy use in emergency department patients diagnosed with ureteral stones

ObjectiveRecent studies have clarified the role of alpha-blockers, such as tamsulosin, for patients diagnosed with ureteral stones <10mm not requiring an urgent intervention. Prior studies have reported low rates of use of MET by emergency physicians. We sought to describe patterns of alpha-blocker use and to determine factors associated with utilization in patients diagnosed with ureterolithiasis in the ED. MethodsWe used data from a randomized trial of CT scan vs. ultrasound in participants with suspected urolithiasis enrolled at 15 EDs between October 2011 and February 2013. The use of medical expulsive therapy was identified by the prescription of an alpha-blocker, calcium channel blocker, or steroid at the ED visit. The prevalence of alpha-blocker use in participants with ureteral stones on imaging was calculated, and multivariable models were used to examine risk factors for utilization. ResultsOf the 524 participants who were identified with a ureteral stone on CT scan and discharged from the ED, 375 (71.4%) received an alpha-blocker, and 2 (<1%) received a steroid. There was no significant difference in alpha-blocker use for participants based on stone size or location. However, there was a 3.6-fold difference in alpha-blocker use between the lowest and highest use ED sites. In the multivariable analysis, ED site was independently associated with utilization of alpha-blockers. ConclusionsAlpha-blockers were prescribed in more than two-thirds of patients with a distal ureteral stone on imaging, a much higher prevalence than previously reported. There was substantial variability in alpha-blocker use based on ED site.

Опыт обобщенной оценки культурной динамики на многослойных памятниках (по материалам энеолитических крепостей Закубанья)

Опыт обобщенной оценки культурной динамики на многослойных памятниках (по материалам энеолитических крепостей Закубанья)

A Generalized Assessment of Cultural Changes at Stratifi ed Sites: The Case of Chalcolithic Fortresses in Northwestern Caucasus

A multivariate method for assessing cultural changes at stratified sites is proposed. Variables are technological properties of ceramics and occurrences of various categories of fl int implements. The method is applied to stratigraphic sequences of Chalcolithic fortresses in northwestern Caucasus (late 5th–early 4th millennia BC): Meshoko and Yasenova Polyana. Properties of ceramics include hardness, assessed on the Mohs scale, wall thickness, and frequency of fragments tempered with calcium carbonate. For Meshoko, S.M. Ostashinsky’s data on the number of implements made of colored flint, splintered pieces, and the total number of segments, points, inserts, scrapers, and perforators were used as well. Each parameter undergoes regular changes from the lower to the upper levels of the sequence: ceramics progressively deteriorates whereas fl int industry becomes more and more sophisticated. These changes occur in parallel. Data were subjected to principal component analysis. The fi rst principal component is regarded as a generalized measure of cultural change. Results support the view of the excavators: changes were caused by the interaction of two cultures differing in origin. The earlier culture, associated with constructors of the Meshoko fortress, shows no local roots and was evidently introduced from Transcaucasia. One that replaced it was signifi cantly more archaic, a few copper tools notwithstanding, and revealed local Neolithic roots. It alone can be termed the Culture of Ceramics with Punched Node Decoration. The ceramics of Yasenova Polyana, too, indicates cultural heterogeneity and two stages of settlement, but cultural changes are more complicated there, probably because the site existed longer, and more than two cultural components were involved.

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

BackgroundScientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a...