Emergency Center Visits Research Articles

546. COVID-19 Monoclonal Antibody Use at a Stand Alone Children’s Hospital

Abstract Background Texas Children’s Hospital (TCH) implemented an outpatient clinic for eligible patients to receive infusions when COVID monoclonal antibodies (mAbs) were approved for use in non-hospitalized, high-risk patients with mild to moderate COVID-19. There are limited data evaluating the use of outpatient COVID mAbs in pediatric patients. We describe the clinical characteristics and outcomes of the patients treated with COVID mAbs at TCH. Methods Patients that were referred to receive COVID mAbs from 12/1/2020 to 5/5/2022 were included. Information collected included demographics, comorbidities, refusal reason, adverse events, emergency center (EC) visits or admission within 14 days after final dose, and EC visit or admission within 14 days of referral if patients did not receive COVID mAbs. Chi-square was used to determine differences between the groups. Results There were 262 patients referred during the study period. The median age of all referred patients was 15.8 years (IQR 14-17.4 years). Majority of referrals were for treatment of COVID-19 infection rather than post-exposure prophylaxis (92.8% vs 7.2%). Of the 262 referrals, 134 patients received COVID mAbs (51.2%) while 128 patients were not treated. Majority of the patients received casirivimab-imdevimab (73.9%). The comorbidities of all patients are shown in Figure 1. The most common reasons for patients to not receive COVID mAbs were no drug available or not listed, and the full list of reasons are listed in Figure 2. The median time from reported symptom onset to infusion was 4 days (IQR 2-6 days). Of the 134 infused patients, 8 patients (6%) visited the EC within 14 days from infusion, and 6 (4.5%) were admitted while 4 patients (3.1%) that did not receive an antibody visited the EC resulting in 3 admissions (2.3%) (EC visits p=0.27; admissions p=0.34). There were 11 patients (8.2%) that experienced adverse events from their infusion, which led to 5 of the 8 EC visits. Comorbidities were similar across the infused and non-infused groups (p=0.16). Number of high-risk conditions represented by all referred, high-risk patients Number of patients for each reason for not receiving a COVID-19 antibody infusion Conclusion COVID mAb treatments were well tolerated among pediatric patients. Majority of patients in both groups did not require EC visit or hospitalization. More data are needed to determine the clinical efficacy of mAbs patients. Disclosures Flor M. Munoz, MD, MSc, CDC respiratory virus surveillance: Grant/Research Support|Gilead: Grant/Research Support|Moderna, sanofi, aztra zeneca, Merck, GSK: Advisor/Consultant|NIH: DSMB|NIH COVID-19 vaccines in pregnancy: Grant/Research Support|Pfizer Pediatric COVID-19 vaccines: Grant/Research Support|Pfizer, Dynavax, Monderna, Meissa, NIH: DSMB Lisa Forbes Satter, MD, ADMA: Advisor/Consultant|CsL Behring: Advisor/Consultant|Grifols: Advisor/Consultant|incyte: Advisor/Consultant|Pharming: Advisor/Consultant|Takeda: Advisor/Consultant

Effect of gold laser energy delivery on postoperative adenotonsillectomy complications.

This study aimed to determine if the energy delivered by the Gold laser impacted postoperative complication rates after adenoidectomy, tonsillectomy, or adenotonsillectomy. A retrospective chart review identified 420 patients who met the criteria within the last five years. Indications for the surgeries included recurrent tonsillitis, obstructive sleep apnea, sleep-disordered breathing, adenoiditis, peritonsillar abscess, and other indications. The relationship between the energy delivered (kJ) and various complications such as bleeding, pain, dehydration, readmission, emergency center visits, and clinic calls was evaluated. There was a significant correlation between higher kJ delivered and the incidence of major bleeding requiring cauterization in the operating room (p=0.0311). In addition, emergency center visits (p=0.0131) and readmission (p=0.0210) showed a significant correlation with the amount of energy (kJ) delivered. Furthermore, higher energy correlated to higher maximum post-operative pain scores (p=0.0302). Attendings displayed a different pattern of energy delivery compared to residents (p<0.0001), which also differed by PGY (p<0.0001). There are significant correlations between higher energy delivered in kJ using the Gold laser and less desirable post-operative results. In addition, residents tend to utilize higher energy levels than attendings, but this trend tapers off in the 4th and 5th years. Clinicians utilizing the Gold laser during these procedures should be mindful of the amount of kJ they use.

Analgesia use in trauma patients at a university teaching hospital in Kigali, Rwanda.

While trends in analgesia have been identified in high-income countries, little research exists regarding analgesia administration in low- and middle-income countries (LMIC). This study evaluates analgesia administration and clinical characteristics among patients seeking emergency injury care at University Teaching Hospital-Kigali in Kigali, Rwanda. This retrospective, cross-sectional study utilized a random sample of emergency center (EC) cases accrued between July 2015 and June 2016. Data was extracted from the medical record for patients who had an injury and were ≥ 15 years of age. Injury-related EC visits were identified by presenting complaint or final discharge diagnosis. Sociodemographic information, injury mechanism and type, and analgesic medications ordered and administered were analyzed. Of the 3,609 random cases, 1,329 met eligibility and were analyzed. The study population was predominantly male (72%) with a median age of 32 years and range between 15 and 81 years. In the studied sample, 728 (54.8%) were treated with analgesia in the EC. In unadjusted logistic regression, only age was not a significant predictor of receiving pain medication and was excluded from the adjusted analysis. In the adjusted model, all predictors remained significant, with being male, having at least one severe injury, and road traffic accident (RTA) as injury mechanism being significant predictors of analgesia administration. In the study setting of injured patients in Rwanda, being male, involved in RTA or having more than one serious injury was associated with higher odds of receiving pain medication. Approximately half of the patients with traumatic injuries received pain medications, predominantly opioids with no factors predicting whether a patient would receive opioids versus other medications. Further research on implementation of pain guidelines and drug shortages is warranted to improve pain management for injured patients in the LMIC setting.

Management of Adverse Events in Early Clinical Trials by Advanced Practice Providers in the Outpatient Setting: The University of Texas MD Anderson Cancer Center Experience.

Background:Advanced practice providers (APPs) play important roles in enrolling, educating, and caring for patients in clinical trials. However, much remains unknown about the role of APPs in managing adverse events (AEs) in early (phase I to II) clinical trials. In this study, we assessed the outpatient management of grade 3 to 4 AEs by APPs in early trials and characterized the workflow of our APP Phase I to II Fast Track (FT) Clinic.Patients and Methods:We retrospectively reviewed records of patients with advanced or metastatic solid tumors enrolled in phase I to II clinical trials who were seen by APPs from September 2017 to August 2018 in the APP phase I to II FT clinic in the Department of Investigational Cancer Therapeutics.Results:A total of 808 patients enrolled in 159 clinical trials were seen in 2,697 visits (median 3 visits per patient; range 1–28) by 10 APPs. Treatment was interrupted in 6.9% of visits, and grade 3 to 4 AEs were seen in 5.4% of visits; however, patients from 1.4% of visits were sent to the emergency center (EC) and/or admitted. Patients referred to the EC and/or admitted were more likely to have baseline hypoalbuminemia, high lactate dehydrogenase, and poor Eastern Cooperative Oncology Group performance status (i.e., ECOG > 1; p < .001). There were no associations between EC referral and gender, APP years of experience, or type of treatment.Conclusions:The APP Phase I to II FT Clinic has an important role in the management of AEs by APPs in early clinical trials in the outpatient setting, potentially avoiding EC visits and admissions.

Improving the safety of outpatient parenteral antimicrobial therapy for patients with solid tumors

Background and objectivesOutpatient parenteral antimicrobial therapy (OPAT) for infections has been in use for nearly 40 years, and although it has been found safe and efficacious, its use has been studied primarily among otherwise healthy patients. We aimed to develop and evaluate an OPAT program for patients with cancer, particularly solid tumors.MethodsWe implemented multiple quality improvement interventions between June 2018 and January 2020. We retrospectively and prospectively collected data on demographics, the completeness of infectious diseases (ID) physician consultation notes, rates of laboratory test result monitoring, ID clinic follow-up, and 30-day outcomes, including unplanned OPAT-related readmissions, OPAT-related emergency center visits, and deaths.ResultsCompleteness of ID provider notes improved from a baseline of 77 to 100% (p < .0001) for antimicrobial recommendations, 75 to 97% (p < .0001) for follow-up recommendations, and 19 to 98% (p < .0001) for laboratory test result monitoring recommendations. Completion of laboratory tests increased from a baseline rate of 24 to 56% (p = .027). Thirty-day unplanned OPAT-related readmission, ID clinic follow-up, 30-day emergency center visit, and death rates improved without reaching statistical significance.ConclusionsSustained efforts, multiple interventions, and multidisciplinary engagement can improve laboratory test result monitoring among solid tumor patients discharged with OPAT. Although demonstrating a decrease in unplanned readmissions through institution of a formal OPAT program among patients with solid malignancies may be more difficult compared with the general population, the program may still result in improved safety.

625. Sustained Efforts Improve Adherence to Monitoring for Solid Tumor Patients Discharged on Outpatient Parenteral Antimicrobial Therapy (OPAT) at a Comprehensive Cancer Center

BackgroundOPAT helps reduce hospital length of stay, but 1 in 4 patients is readmitted within 30 days of discharge. Follow up < 30 days after discharge and laboratory monitoring during therapy have been shown to reduce hospital readmissions. However, few OPAT studies have included patients with malignancies, who may not experience the same benefits due to increased risks for hospital admission and infection related to antineoplastic therapy. We started an OPAT program to increase laboratory monitoring and clinic follow up among patients with solid tumors, attempting to also decrease readmissions.MethodsWe obtained demographic data and baseline frequencies of laboratory monitoring, ID clinic follow up, 30-day OPAT-related readmissions, Emergency Center (EC) visits, and deaths by retrospective chart review. We conducted multiple interventions from June 2018-January 2020: clarifying physician recommendations for laboratory monitoring and follow up by using a standardized electronic medical record template, communicating recommendations to case management, and changing the lab ordering workflow. We compared frequencies after interventions to baseline by using Fisher’s exact test.ResultsMost commonly observed malignancies in our patient cohort included genitourinary, breast, gastrointestinal, gynecologic, and head and neck. The most commonly treated infections included abscess, bacteremia, and skin and soft tissue. The percentage of patients without recommended lab monitoring decreased from 32.3% to 15.3% (p=0.03). We observed trends toward improved ID clinic follow up (54.8% to 71.8%; p=0.12) and decreased 30-day OPAT-related readmissions from 16.7% to 8.6% (p = 0.17). We observed no difference in mortality or EC visits.ConclusionOPAT-treated infections in our solid tumor patient cohort differed from those reported commonly. Through continued interventions, we improved lab monitoring rates among solid tumor patients with trends toward improved ID clinic follow up and decreased readmission rates. Our findings suggest that despite competing reasons for hospital readmission, OPAT may still benefit this population.Disclosures All Authors: No reported disclosures

Early Identification of Pediatric Neurology Patients With Palliative Care Needs: A Pilot Study.

Palliative care services are beneficial for pediatric neurology patients with chronic, life-limiting illnesses. However, timely referral to palliative care may be impeded due to an inability to identify appropriate patients. The aim of this pilot case-control study was to test a quantitative measure for identifying patients with unmet palliative care needs to facilitate appropriate referrals. First, a random subset of pediatric neurology patients were screened for number of hospital admissions, emergency center visits, and problems on the problem list. Screening results led to the hypothesis that having six or more hospital admissions in one year indicated unmet palliative care needs. Next, hospital admissions in the past year were counted for all patients admitted to the neurology service during a six-month period. Patients with six or more admissions as well as age- and gender-matched controls were assessed for unmet palliative care needs. In hospitalized pediatric neurology patients, having six or more admissions in the preceding year did not predict unmet palliative care needs. While this pilot study did not find a quantitative measure that identifies patients needing a palliative care consultation, the negative finding highlights an important distinction between unmet social needs that interfere with care and unmet palliative care needs. Further, the method of screening patients used in this study was simple to implement and provides a framework for future studies.

Outcomes of Embedded Palliative Care Outpatients Initial Consults on Timing of Palliative Care Access, Symptoms, and End-of-Life Quality Care Indicators among Advanced Nonsmall Cell Lung Cancer Patients.

To determine the timing of palliative care (PC) access, symptoms, and end-of-life (EOL) quality care outcomes of patients with advanced nonsmall cell lung cancer (NSCLC) referred to outpatients embedded palliative care consults (EPC) compared with those of outpatients palliative care consults (OPC). There are no studies comparing the outcomes of outpatients EPC consults with those of stand-alone OPC consults among patients with NSCLC. The design consists of a random sample of OPC consults (January 2009 to July 2012) and EPC consults (August 2012 to June 2013) at MD Anderson Cancer Center. After the initial consult, all EPC follow-ups occurred at the OPC clinic. Patients' characteristics, symptoms (assessed by Edmonton Symptom Assessment Scale), time from referral to first consult, overall survival from consult to death, and EOL quality care outcomes (ICU admissions, emergency center visits, hospitalizations within last 30 days, cancer treatments within last 14 days, hospice referrals, advanced care planning [ACP] discussions, and completion of advanced directives) were reviewed. A total of 340 consults were included (EPC consults = 147). Baseline Eastern Cooperative Oncology Group status (2.2 vs. 1.9, p < 0.001) and median pain (6 vs. 5, p = 0.038) were higher among EPC consults. In EPC consults, time from referral to first consult was shorter (median: 0 day vs. 7 days, p < 0.001), and ACP discussions occurred more frequently (90% vs. 77%, p = 0.026), and earlier (median: 2 month vs. 1 month before death, p = 0.018). No other significant differences in symptoms, EOL outcomes, or survival were observed. EPC consults plus OPC follow-ups accessed PC earlier, and had more frequent and earlier ACP discussions as compared with OPC consults. Embedded palliative cancer care might not be the ideal model for an initial PC consultation. Further research is necessary.

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe.

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways.

How to Control Physicians' Overutilization of Resources to Reduce the Health Services Costs?

The increasing cost of health services and the limited financial resources available force countries to find approaches to reduce cost and to improve the quality of health services. Variations in physicians practice patterns have important implications for quality and cost. Because of their central role in health care, the hospital administrators should establish some control systems that can modify the current application models of physicians. Therefore, many countries are trying to control overutilization through different strategies. Common areas of overutilization include hospitalization, hospital inpatient days, emergency center visits, diagnostic laboratory and radiology tests, and prescription drugs.

1751 Childproofing Cannot be Safely Assumed after Accidental Poison Ingestion Related Hospital Visits

Background/aims:Data is scant on the follow up of the patients after accidental poison ingestions. We wanted to determine if the parents of children with recent accidental poison ingestions took any...

Progressive disease in patients with cancer presenting to an emergency room with acute symptoms predicts short-term mortality

Patients with symptomatic, advanced cancer continue to be referred late or not at all for hospice or palliative care. We conducted a retrospective cohort study to determine whether evidence of cancer progression is an independent predictor of short-term mortality in acutely symptomatic cancer patients. We reviewed the records of 396 patients who visited the emergency center at a comprehensive cancer center in January 2000. Records were reviewed for clinical characteristics, including symptoms, type and extent of cancer, and whether the patient's cancer was stable or progressing (uncontrolled) at the time of the emergency center visit. Cox regression analysis was used to assess survival at 90 and 180 days, after controlling for patient characteristics. Patients who died within 14, 90, or 180 days were more likely to have disease progression than those who did not. Dyspnea on emergency center presentation and disease progression were independent predictors of death within 90 or 180 days, after controlling for patient age, symptoms, signs, and the presence of metastases. The odds ratios for death within 90 and 180 days were 3.97 and 4.34, respectively (95% confidence intervals: 1.44, 10.94 and 1.87, 10.09). Cancer disease progression is a clinical measure of increased risk of short-term mortality in acutely symptomatic cancer patients. Future studies should examine whether the use of this characteristic enhances identification of patients who could benefit from timely referral to hospice or palliative care. Symptomatic cancer patients presenting to a cancer center emergency room were more likely to die within 14, 90, or 180 days if they had evidence of recent progression of their cancer. Among patients with disease progression, 47% died within 90 days and 61% within 180 days.

Viral respiratory infections in elderly patients and patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) and elderly individuals are prone to the development of significant lower respiratory tract symptoms from colds caused by viral respiratory pathogens. Longitudinal surveillance studies conducted to assess the impact of viral respiratory tract pathogens on morbidity and mortality in each of these at-risk populations demonstrate that there is a substantial burden of disease from viral respiratory infection (VRI), including rhinovirus infections, with respect to utilization of health-care resources. Despite a similar rate of occurrence of VRI among subjects with COPD and the control group, a cohort with moderate to severe COPD had a 2-fold increase in medical resource utilization, including clinician visits, emergency center visits, and hospitalizations. In surveillance studies of respiratory viruses in the elderly, regular seasonal infections with rhinoviruses cause substantial morbidity, which has been largely underappreciated and underreported.

Viral respiratory infections in elderly patients and patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) and elderly individuals are prone to the development of significant lower respiratory tract symptoms from colds caused by viral respiratory pathogens. Longitudinal surveillance studies conducted to assess the impact of viral respiratory tract pathogens on morbidity and mortality in each of these at-risk populations demonstrate that there is a substantial burden of disease from viral respiratory infection (VRI), including rhinovirus infections, with respect to utilization of health-care resources. Despite a similar rate of occurrence of VRI among subjects with COPD and the control group, a cohort with moderate to severe COPD had a 2-fold increase in medical resource utilization, including clinician visits, emergency center visits, and hospitalizations. In surveillance studies of respiratory viruses in the elderly, regular seasonal infections with rhinoviruses cause substantial morbidity, which has been largely underappreciated and underreported.

Identifying Risk Factors for Imminent Death in Cancer Patients with Acute Dyspnea

A substantial proportion of cancer patients presenting to an emergency center (EC) or clinic with acute dyspnea survives fewer than 2 weeks. If these patients could be identified at the time of admission, physicians and patients would have additional information on which to base decisions to continue therapy to extend life or to refocus treatment efforts on palliation and/or hospice care alone. The purpose of this study was to identify risk factors for imminent death (survival ⩽ 2 weeks) and short-term survival (1, 3, or 6 months) in cancer patients presenting to an EC with acute dyspnea and to combine these factors into a model to help clinicians identify patients with short life expectancies. A random sample of 122 patients presenting to an EC with acute dyspnea was selected for a retrospective analysis. Data that were available to physicians during the initial EC visit included patient histories, triage and discharge vital signs, chest radiographs, and laboratory results. These variables were used in univariate and logistic regression models to develop predictive models for imminent death and short-term survival. Variables and interactions meeting a univariate criterion of P < 0.10 were included in stepwise regression by using forward and backward stepping. Models were compared with the use of Hosmer–Lemeshow statistics and receiver operating characteristics curves. Underlying cancers were 30% breast, 37% lung, and 34% other cancers. Triage respiration greater than 28/min., triage pulse greater than or equal to 110 bpm, uncontrolled progressive disease, and history of metastasis were found to be statistically significant predictors (α ⩽ 0.05) of imminent death. Patients with uncontrolled progressive disease had a relative risk of imminent death of 21.93. Relative risks for triage respiration, pulse, and metastases were 12.72, 4.92, and 3.85, respectively. Cancer diagnosis was not predictive of imminent death but was predictive when longer time periods were modeled. It may be possible to identify patients whose death is imminent from a group of cancer patients with acute dyspnea. Some factors that predict imminent death (triage pulse and respiration) differ from those (cancer diagnosis) that predict short-term survival. Extent of disease/response to treatment is common to all models. These factors need further examination and validation. If these findings are confirmed, this quantified information can help physicians in making difficult end-of-life decisions.

Respiratory viral infections in adults with and without chronic obstructive pulmonary disease.

A longitudinal cohort study of older adults with chronic obstructive pulmonary disease (COPD) who were stratified by FEV(1) at enrollment was done to define the etiology, frequency, severity, and medical-care impact of respiratory tract viral infections (RTVIs). Controls consisted of a group of subjects of comparable age with the patients. RTVIs were documented in 44% of observed acute respiratory illnesses in control subjects and in 27% of COPD subjects, who were followed for mean periods of 35 and 26 mo, respectively. In this heavily influenza-vaccinated cohort ( approximately 90% vaccinated each year), picornaviruses, parainfluenza viruses, and coronaviruses were most commonly identified. Mean time to return to clinical baseline was approximately 2 wk in each group. Control and COPD subjects with mild airways obstruction (baseline FEV(1) >/= 50% predicted) had few emergency-center visits or hospitalizations. Approximately half of COPD subjects with moderate/severe COPD (baseline FEV(1) < 50% predicted) had at least one emergency-center visit and/or hospitalization for acute respiratory illness. RTVIs were documented in 23% of hospitalizations and in 45% of patients admitted between December and March. RTVIs have a major impact on utilization of health care resources for COPD patients with moderate/severe airways obstruction.

Assessing parental utilization of the poison center: an emergency center-based survey.

The purpose of this study was to identify and characterize caretakers who fail to utilize the poison center for unintentional poisonings involving children. We interviewed 210 caretakers of children evaluated for unintentional poisoning in the emergency center of an urban, university-based teaching hospital to determine (1) whether demographic differences exist between those caretakers who contacted a poison center prior to the emergency center visit and those who did not and (2) whether differences exist in prevalence of poison prevention knowledge and behaviors between the two groups. Ninety-six (46%) of caretakers did not contact the poison center prior to the emergency center visit. Significant differences were found between the two groups for the following caretaker variables: race/ethnicity, language preference, age, level of education, country in which schooling occurred, and type of insurance coverage for the child. When logistic regression was used to control for confounding, the two variables associated with failure to use the poison center were black race and schooled outside the United States (primarily in Mexico). Poison center callers reported a higher prevalence of poison prevention knowledge and behaviors than noncallers. Educational interventions should be targeted to the groups of caretakers identified who do not use the poison center.

959-105 Emergency Center Tc99m-sestamibi SPECT Imaging for Unexplained Chest Pain: Cost Savings and Outcome Analysis

Emergent myocardial perfusion imaging (MPI) has been shown to be accurate in diagnosis of acute MI. We assessed the financial and pt outcome implications of such imaging. 50 pts presenting to emergency center (EC) with unexplained chest pain received resting Tc99m-sestamibi SPECT MPI as part of their EC evaluation with a gamma camera dedicated to this purpose. If resting scan was nl, adenosine stress imaging was performed in EC at cardiologist's (MD) discretion. Influence of MPI was determined by MD questionnaire completd immediately before and after MPI results were made available. Cost savings analysis was based on pre- vs post-MPI management strategy and historical analysis of costs. 45 pts were followed avg 9 months post MPI. MPI altered pt management in 34/50 pts (68%). 29 pts were sent home rather than admitted based on EC MPI. 9/21 admitted pts were sent to lower intensity beds. Total cost savings was $88,533 ($1771/pt) . 35 pts were asymptomatic on follow-up, 8 had recurrent chest pain and 6 had at least 1 EC visit for chest pain. No pt with nl MPI had a major cardiac event or revascularization on follow-up. The use of acute EC SPECT MPI is a cost effective means of assigning pts to a low risk group that may be followed safely on an outpatient basis.