Emergency Department Administration Research Articles

Update on nonantibiotic therapies for acute gastroenteritis.

The aim of this review is to provide an update of nonantibiotic therapies for acute gastroenteritis (AGE), focusing on antiemetics and probiotics. The mainstay of therapy for nonsevere AGE remains oral rehydration therapy (ORT). Recent randomized controlled trials and metaanalyses have further strengthened the evidence-base supporting single-dose ondansetron administration in emergency departments to facilitate ORT based on evidence that it safely reduces intravenous fluid administration and hospitalization rates. Intravenous ondansetron administration and multiple-dose use should be avoided. A bimodal release ondansetron formulation was shown to improve outcomes in adolescents and adults with AGE in one study, but further evidence is required to support use. Recent large trials evaluating probiotic administration demonstrated a lack of benefit and guidelines that recommend their use should reevaluate their positions in light of this evidence. Furthermore, caution should be exercised when use is considered in high-risk populations and settings. The benefits, dosing/route, and target populations most likely to benefit from ondansetron have been further clarified. Optimization of the real-life effectiveness of this therapy will require implementation strategies. Recent high-quality evidence showing a lack of efficacy and potential harm associated with probiotic use suggests that routine use for AGE should be discouraged.

Association of Emergency Department Opioid Administration With Ongoing Opioid Use: A Retrospective Cohort Study of Patients With Back Pain.

Opioids are commonly administered in the emergency department (ED) and prescribed for the treatment of back pain. It is important to understand the unintended consequences of this approach to inform treatment decisions and the consideration of alternative treatments. Recent evidence has shown that ED opioid prescriptions are associated with future opioid use. The objective of this study was to measure the association of opioid administration in the ED to patients treated for back pain with future opioid use. This is a retrospective study of opioid-naïve adults discharged from the ED with a diagnosis of back pain. Patients were stratified by opioid therapy (none, ED administration only, prescription only, or ED administration+prescription). Relative risks of ongoing opioid use (filling >90-day supply in 180days following ED visit as documented in the prescription drug monitoring program) were calculated for each opioid-therapy group and compared to the no-opioid group. We identified 24,487 opioid naïve back pain patients. The median age was 38years, 55% were female, and 56% were non-Hispanic white. A total of 41% received no opioid, 10% were only administered an opioid in the ED, 18% only received a prescription, and 31% received an opioid in the ED+prescription. The adjusted relative risks of ongoing use compared to the no opioid group were as follows: ED only 1.9, prescription only 2.1, and ED+prescription 2.3. The increased risk persisted for other definitions of ongoing use and after adjustment for baseline pain scores. For opioid-naïve patients with back pain, both administration of an opioid in the ED and opioid prescriptions are associated with a doubling of the risk of ongoing opioid use compared to patients not treated with opioids. This supports the consideration of minimizing exposure to opioids while treating back pain in the ED.

Enhancing patient flow in emergency department (ED) using lean strategies–an integrated voice of customer and voice of process perspective

PurposeThe purpose of this paper is to systematically investigate the patient flow and waiting time problems in hospital emergency departments (EDs) from an integrated voice of customer (VOC) and voice of process (VOP) perspective and to propose a new lean framework for ED process.Design/methodology/approachA survey was conducted to better understand patients' perceptions of ED services, lean tools such as process mapping and A3 problem-solving sheets were used to identify hidden process wastes and root-cause analysis was performed to determine the reasons of long waiting time in ED.FindingsThe results indicate that long waiting times in ED are major concerns for patients and affect the quality of ED services. It was revealed that limited bed capacity, unavailability of necessary staff, layout of ED, lack of understanding among patients about the nature of emergency services are main causes of delay. Addressing these issues using lean tools, integrated with the VOC and VOP perspectives can lead to improved patient flow, higher patient satisfaction and improvement in ED capacity. A future value stream map is proposed to streamline the ED activities and minimize waiting times.Research limitations/implicationsThe research involves a relatively small sample from a single case study. The proposed approach will enable the ED administrators to avoid the ED overcrowding and streamline the entire ED process.Originality/valueThis research identified ED quality issues from the integration of VOC and VOP perspective and suggested appropriate lean tools to overcome these problems. This process improvement approach will enable the ED administrators to improve productivity and performance of hospitals.

Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis

Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBDpatients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p< 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.

Risk of Acute Kidney Injury Associated With Medication Administration in the Emergency Department.

Patients who develop acute kidney injury (AKI) have a 2-fold increased risk for major adverse events within 1year. An estimated 19-26% of all cases of hospital-acquired AKI may be attributable to drug-induced kidney disease (DIKD). Patients evaluated in the emergency department (ED) are often prescribed potentially nephrotoxic drugs, yet the role of ED prescribing in DIKD is unknown. We sought to measure the association between ED medication administration and development of AKI. This was a retrospective 5-year cohort analysis at a single center. Patients with a serum creatinine measurement at presentation in the ED and 24-168h later were included. Outcome was incidence of AKI as defined by Kidney Disease Improving Global Outcomes criteria in the 7days after ED evaluation. Medication administration risk was estimated using Cox proportional hazards model. There were 46,965 ED encounters by 30,407 patients included in the study, of which 6461 (13.8%) patients met the criteria for AKI. For hospitalized patients, administration of a potentially nephrotoxic medication was associated with increased risk of AKI (hazard ratio [HR] 1.30 [95% confidence interval {CI} 1.20-1.41]). Diuretics were associated with the largest risk of AKI (HR 1.64 [95% CI 1.52-1.78]), followed by angiotensin-converting enzyme inhibitors (HR 1.39 [95% CI 1.26-1.54]) and antibiotics (HR 1.13 [95% CI 1.05-1.22]). For discharged patients, administration of antibiotics was strongly associated with increased risk of AKI (HR 3.19 [95% CI 1.08-9.43]). ED administration of potentially nephrotoxic medications was associated with an increased risk of AKI in the following 7days. Diuretics, angiotensin-converting enzyme inhibitors, and antibiotics were independently associated with increased risk of AKI. Nephroprotective practices in the ED may mitigate kidney injury and long-term adverse outcomes.

Buprenorphine Initiation in the Emergency Department: a Thematic Content Analysis of a #firesidetox Tweetchat

The height of the opioid epidemic in the USA has led to an increasing call for access to medication assisted treatment for opioid use disorder, including buprenorphine initiation from the emergency department (ED). However, only a small percentage of emergency physicians feel prepared or have the necessary training to prescribe buprenorphine. Twitter has increasingly been used as a tool for medical education, and there is growing interest in using this forum to actively engage medical providers and the public. This study examined the views regarding ED initiation of buprenorphine treatment among contributors to the quarterly American College of Medical Toxicology (ACMT) tweetchat, #firesidetox, and the demographics of the participants. A mixed methods descriptive study was conducted to analyze individual responses and self-identified demographics among Twitter users participating in the #firesidetox tweetchat regarding the ACMT position statement about ED initiation of buprenorphine treatment. This tweetchat included 86 participants, the majority of whom were clinicians in the USA. Physicians accounted for 46% of participants primarily emergency medicine physician toxicologists and authored 75% of the tweets. It consisted of 317 tweets which most frequently described clinical vignettes or experience (46%) or medical education (25%) related to buprenorphine and had themes related to treatment initiation location (ED vs outpatient vs home) (8.6%) and challenges and solutions to buprenorphine administration (8.6%). A tweetchat can be used to disseminate and discuss the adoption of buprenorphine in the ED. Importantly, the tweetchat provides a forum for experts to share narratives and expertise on implementation and barriers and successes in operationalizing buprenorphine administration in emergency departments.

Disparities and Variables Associated With Physical Restraint for Acute Agitation in a Nonpsychiatric Emergency Department.

To determine associations between the rate of physical restraint and demographic variables such as body mass index (BMI), ethnicity, sex, and age in the emergency department (ED) along with clinical variables such as various psychiatric diagnoses and medications. This 6-month (October 1, 2016-March 30, 2017) retrospective chart review was conducted in the ED of a community hospital, which is also a teaching institution for medical students and residents but does not have access to psychiatry consultations via phone or in person. A total of 165 agitated patients were included in the study. Agitated patients who were restrained were compared to those who were not physically restrained. Of the patients, 112 (68%) were physically restrained, and those not physically restrained were included as controls (n = 53, 32%). Younger age (P = .03), lower BMI (P = .04), intoxication (P = .001), preexisting diagnosis of depression (P = .02), and antipsychotics as a home medication (P = .03) were associated with physical restraints. In the ED, administration of haloperidol and olanzapine was associated with physical restraints. Current benzodiazepine prescription (P = .001), ED administration of ketamine (P = .001), and ED administration of diazepam (P = .001) were more common in those not physically restrained. Risk factors for physical restraints can be used to identify high-risk patients early, and other treatments along with behavioral and environmental modifications may then be utilized. Further research to develop protocols using nonpharmacologic and pharmacologic measures to minimize use of restraints is required.

REFINING AN ELDER MISTREATMENT SCREENING AND RESPONSE TOOL TO IMPROVE ACCEPTABILITY IN AN EMERGENCY DEPARTMENT

Elder mistreatment (EM) is a public health problem that is rarely recognized or addressed in emergency departments (ED) where a lack of evidence-based protocols leave clinicians to rely on intuition and inconsistent action plans. In this presentation we will share findings from focus groups and online surveys with ED clinicians and administrators to evaluate the perceived value and likelihood of adopting the National Collaboratory’s third core element: the EM Screening and Response Protocol (EM-SAR). Results indicated a strong support for the EM-SAR tool in general and highlighted specific considerations for refining the tool. Considerations include resistance to adding to the ED workload, need to clarify roles and responsibilities for administering the tool, hesitancy to rely on clinical judgement to assess EM, concerns over Adult Protective Services’ ability to respond to increased reports, and a desire for cross-training and cooperation. These findings and implications for ongoing feasibility testing will be discussed.

1006. Do Antibiotic Choices Made in the ED Influence Inpatient Therapy?

BackgroundInappropriate antibiotic use (AU) is common among inpatients and may begin in the emergency department (ED). ED clinicians often make the first antibiotic decisions in patient care, but it is unknown whether or not these decisions influence inpatient AU. Understanding prescribing practices at transitions of care is critical for implementing effective stewardship initiatives.MethodsWe performed a retrospective cohort study of AU in patients admitted to Duke University Hospital through the ED between July and December 2018. Included encounters had a minimum 2-day length of stay and received an antibiotic in both the ED and inpatient setting. Individual encounter IDs were used to link ED and inpatient AU reports generated from the DASON Antimicrobial Stewardship Assessment Portal. We compared the last ED administration date/time to the first inpatient unit administration for each agent. An antibiotic started in the ED was considered continued upon admission if the first inpatient administration occurred within 30 hours following the last ED administration. Demographic, clinical indication on order entry, length of therapy, and prescriber data were also collected.ResultsWe included 3,336 encounters and 2,940 unique patients in the analysis. The median (IQR) patient age was 60 (42–72) years, and the most common indications for AU in the ED were sepsis (23.1%), pneumonia (17.8%), ABSSSI (15.5%), and intra-abdominal infection (12.8%). At least one antibiotic initiated in the ED was continued upon admission within 30 hours in 2,495 (74.8%) encounters. The most common antibiotics continued upon admission were piperacillin/tazobactam (32.8%), vancomycin (24.9%), and ceftriaxone (13.7%). The most common indications for agents continued upon admission were pneumonia (18%), intra-abdominal infection (15%), and ABSSSI (15%). Two or more antibiotics were continued upon admission in 916 (27.4%) encounters.ConclusionIn our retrospective review of ED antibiotic encounters resulting in admission for at least 2 days, three out of four encounters had at least one antibiotic continued upon admission. This finding highlights the importance of initial appropriate antibiotic selection and suggests stewardship interventions should target EDs as well as inpatient prescribing.Disclosures All authors: No reported disclosures.

752. Timing of Antibiotics Administration in Emergency Department and Mortality in Sepsis by Sepsis-3 Definition

BackgroundEven after the introduction of the Sepsis-3 definition, there is still debate on the ideal antibiotic administration time in patients with sepsis. This study was performed to evaluate the association between the timing of antibiotic administration and mortality in sepsis patients who visited the emergency room.MethodsA prospective cohort study was conducted on patients who were diagnosed as sepsis with Sepsis-3 definition among patients who visited the emergency department (ED) of Korea University Ansan Hospital from September 2017 to January 2019. The timing of antibiotic administration was defined as the time in hours from ED arrival until the first antibiotic administration. Cox logistic regression analysis was used to estimate the association between time to antibiotics and 7-, 14-, and 28-day mortality.ResultsDuring the study period, a total of 251 patients were enrolled with a 7-, 14-, and 28-day mortality of 16.7%, 36.3%, and 57.4%, respectively. The median time to antibiotic administration was 247 minutes (interquartile range 72 – 202 minutes). The mean age was 72 ± 15 years old and 122 patients (48.6%) were female. The most common site of infection was respiratory infection. The timing of antibiotic administration were not associated with 7-, 14-, and 28-day mortality. Female (adjusted hazard ratio [HR] 2.06 [95% confidence interval (CI) 1.21 – 3.53]; P value = 0.008), SOFA score (aHR 1.17 [95% CI 1.05 - 1.31]; P = 0.005), and initial lactate level (aHR 1.13 [95% CI 1.05 - 1.22]; P = 0.001) increased the risk of 7-day mortality. Female (aHR 2.07 [95% CI 1.48 – 2.89]; P ≤ 0.001), Charlson comorbidity index (aHR 1.12 [95% CI 1.02 - 1.24]; P = 0.025), and initial lactate level (aHR 1.19 [95% CI 1.02 - 1.16]; P = 0.011) increased the risk of 14-day mortality. Female (aHR 1.95 [95% CI 1.50 – 2.54]; P = 0.001) increased the risk of 28-day mortality in patients with sepsis.ConclusionThe timing of antibiotic administration did not increase the risk of mortality in the treatment of sepsis patients who visited ED. Rather, the SOFA score, lactate, female, and comorbidity increased the mortality associated with sepsis. Disclosures All authors: No reported disclosures.

317 Sustainable Naloxone Education and Distribution From an Urban Emergency Department

The opioid epidemic was declared a national emergency in 2017. Naloxone can rapidly reverse fatal overdose and evidence shows reduced mortality when naloxone is available in the community. The optimal naloxone distribution methods are yet to be established. We aim to determine the feasibility and sustainability of instituting a program which provides naloxone in hand to at-risk patients in a high-volume, urban emergency department (ED). Secondary objectives are to describe patient receptiveness to receiving naloxone at ED discharge, medication cost and 30 day follow up. Our study included a convenience sample of patients who presented to the ED between October 2018 and May 2019 who exhibited improvement in mental status after administration of naloxone, either in the ED or via emergency medical services, and who were anticipated to be discharged home from the ED. Enrollment was limited to the outpatient pharmacy work hours: Monday to Friday 7am to 6pm. Eligible patients were identified by ED personnel and were engaged by the ED naloxone educator 1-2 hours prior to anticipated discharge. Patients were asked if they were interested in receiving the naloxone and the administration instructions. If the patient was agreeable to others receiving education with them, others were invited to participate. If no one was available, teach back occurred to ensure the patient could teach others after discharge. The outpatient pharmacy delivered a 2-dose package of 4mg naloxone nasal spray as prescribed by the ED provider prior to discharge. Uninsured patients had medication cost covered by the ED medical needs fund. The pharmacy provided additional financial assistance for those with copays. The ED naloxone educator provided the naloxone administration education along with an informational packet on community resources and follow-up care. Patients were called in follow-up at least 30 days after the date of visit. A total of 30 patients were approached between October 2018 and May 2019, and 27 (90%) patients were successfully enrolled in the study. The cohort was predominantly African American (75%) with a median age of 54 years and male sex (74%). 24/27 (89%) of patients were insured and 20/24 (83%) insured patients had zero copay for naloxone nasal spray. One of 18 (6%) eligible patients for 30 day follow up was successfully contacted. 4/18 (22%) patients who were agreeable to receive naloxone declined to give contact information for 30-day follow-up. The study was initiated as a 1-month pilot and was continued after ED administration noted minimal interference to ED workflow. Utilization of existing ED systems can allow for a sustainable model of naloxone provision and administration instruction. Most patients in the study had zero copay and were receptive to education. Follow-up in this patient population was relatively unsuccessful. Identifying patients nearing the end of an observation period with an anticipated discharge home can allow for naloxone distribution to cause minimal disruption to workflow in a busy ED. This model of naloxone provision can be sustainable without external funding and provides a method to receive prescribed medications while in the ED. Further studies are needed to demonstrate sustainable naloxone distribution.

Establishment of a Unified Quality Indicators System to Increase the Effectiveness of Emergency Departments

The overall quality of an emergency department (ED) can be measured by its ability to provide fast, efficient yet high-quality medical treatments to its patients. The objective of the present study was to derive a common set of key indicators that could be used to assess the quality of the performance of EDs. A modified Delphi process was employed to achieve this. This consisted of a detailed literature review followed by a three-round expert panel interaction, which was used to reduce and refine the list of indicators. The members of the panel comprised ED physicians, ED nurses and hospital and ED administrators drawn from six EDs. This process yielded 47 essential performance indicators and 12 recommended indicators. The performance indicators were classified into 7 main groups according to their characteristics. The chosen indicators comprise a core set that will be used in an ongoing study on a representative sample of EDs.

Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design.

Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer. Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims. Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013. None. Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39). The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.

Abstract WP507: Improvement in Door to Needle Time to Intravenous Thrombolysis With on Site Stroke Activation Nurse

Introduction: Effectiveness of stroke thrombolysis is highly dependent on early initiation of therapy, and strategies have been developed to reduce the door-to-needle time (DTN). Aim: To determine the impact on DTN after introduction of stroke activation nurse (SAN) in a teaching hospital. Methods: Our hospital is the comprehensive stroke center serving western Singapore and admits about 900 acute ischemic stroke patients per year. Previously thrombolysis was commenced after evaluation in the Emergency Department (ED) and admission to the Neurology high-dependency unit, causing considerable delay to treatment. From May 2015, a SAN joined the stroke code and evaluated all thrombolytic candidates, obtained NIHSS scores, calculated the dose and prepared the tPA for administration in ED. From September 2016, addition of a second SAN allowed faster response, especially in simultaneous stroke activations. From a prospective database of our patients treated with thrombolysis, we compared patient characteristics and DTN during three 16-month periods before and after SAN participation: Jan 2014-Apr 2015 (Baseline), May 2015-Aug2016 (Period 1), and Sep 2016-Dec 2017 (Period 2). Results: A total of 555 patients received thrombolysis, with mean age 67.5 years, 41% female, 73% hypertension, 35% diabetes mellitus, 55% hyperlipidemia and 31% atrial fibrillation. More patients were thrombolysed after SAN participation in the stroke code, from 146 (14%) at baseline, to 191 (17.6%) in Period 1 and 218 (18.8%) in Period 2. The median (range) NIHSS scores during these periods were 16 (2-32), 13 (1-33) and 12 (2-35) respectively. Mean (SD) and median DTN at baseline was 80 ( ±32) and 77 mins, which decreased to 63 ( ±32) and 57 mins in Period 1, and 58 ( ±29) and 52 mins in Period 2 . Percentages of patients thrombolysed within 60 mins improved from 25.3% at Baseline to 56.5% and 67% during Periods 1 and 2 respectively. Conclusions: Our results showed that involvement of SAN was associated with decrease in DNT and enabled more patients to be treated with intravenous thrombolysis.

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients.

ObjectiveIdentify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A).Study DesignPediatric Health Information System (PHIS) database analysis.MethodsForty‐seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED.ResultsOf the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed (P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non‐opioids, and only 51 (5.9%) received no pain medication.ConclusionT&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non‐opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity.Level of Evidence4

Pediatric Readiness in the Emergency Department.

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma.

Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.

185 Everyone Loves a Popsicle: A Simple and Affordable Intervention to Improve Patient Satisfaction

Value-based purchasing (VBP) is a quality incentive program under the Affordable Care Act that is funded by a 2% reduction from diagnosis-related group (DRG) payments for the 2018 fiscal year. One-quarter of this fund is determined by patient and caregiver-centered experience and care coordination. Therefore, patient satisfaction scores have become an increasingly important component of health care delivery. Few studies have sought to identify low-cost interventions that improve patient experience and subsequently patient satisfaction scores. Here, we aim to explore the impact of popsicle administration in pediatric emergency department (ED) patients on Press Ganey satisfaction scores. A prospective trial was conducted at a tertiary academic pediatric ED and one mid-sized community ED between January 2018 to March 2018. The intervention was to give a popsicle to all eligible patients 0-14 years of age on even-numbered days (popsicle days) versus conventional practice on odd-numbered days. Press Ganey top box scores (response to the question was a “5” or the highest value) between even- and odd-numbered days were then compared using 2-sample t and chi-square tests. Among the 152 pediatric patients included (0-14 years of age), 84 surveys were filled out on even days and 68 surveys were filled out on odd days. Baseline demographics were similar between the groups with an average age of 7.3 ± 6.0 years and no statistical difference between the number of male and female patients. Overall, there was a significant increase in patient satisfaction scores on popsicle administration days for questions that asked about physician’s concern for comfort 74% versus 58% (p < 0.05), physician’s courtesy 77% versus 62% (p < 0.04), and physician taking time to listen 74% versus 57% (p < 0.03). No statistical difference was observed for questions that asked about overall rating of care 64% versus 61% (p= 0.64), likelihood of recommending 66 versus 59% (p=0.37), or informed of treatment 74% versus 60% (p=0.07). Offering popsicles to all eligible pediatric emergency department patients resulted in an increase in Press Ganey patient satisfaction score regarding physician’s concern for comfort, courtesy, and listening. Further studies should increase sample size, assess subsets of age groups, and assess economic rate of return for this and other low-cost interventions that might significantly impact perceived health care quality.

Prehospital Tranexamic Acid Administration During Aeromedical Transport After Injury

BackgroundTranexamic acid (TXA) has been shown to reduce mortality in the treatment of traumatic hemorrhage. This effect seems most profound when given early after injury. We hypothesized that extending a protocol for TXA administration into the prehospital aeromedical setting would improve outcomes while maintaining a similar safety profile to TXA dosed in the emergency department (ED). Materials and methodsWe identified all trauma patients who received TXA during prehospital aeromedical transport or in the ED at our urban level I trauma center over an 18-mo period. These patients had been selected prospectively for TXA administration using a protocol that selected adult trauma patients with high-risk mechanism and concern for severe hemorrhage to receive TXA. Patient demographics, vital signs, lab values including thromboelastography, blood administration, mortality, and complications were reviewed retrospectively and analyzed. ResultsOne hundred sixteen patients were identified (62 prehospital versus 54 ED). Prehospital TXA patients were more likely to have sustained blunt injury (76% prehospital versus 46% ED, P = 0.002). There were no differences between groups in injury severity score or initial vital signs. There were no differences in complication rates or mortality. Patients receiving TXA had higher rates of venous thromboembolic events (8.1% in prehospital and 18.5% in ED) than the overall trauma population (2.1%, P < 0.001). ConclusionsPrehospital administration of TXA during aeromedical transport did not improve survival compared with ED administration. Treatment with TXA was associated with increased risk of venous thromboembolic events. Prehospital TXA protocols should be refined to identify patients with severe hemorrhagic shock or traumatic brain injury.

A Conceptual Model for Emergency Department Patient Experience.

Emergency department (ED) patient experience continues to be a growing area of focus for ED physicians, administrators, and regulatory agencies. Recent literature has suggested a strong correlation between positive ratings of patient experience and important health system goals, including improved clinical outcomes and care quality, increased staff satisfaction, and reduced medicolegal risk. However, given the myriad of factors driving ED patient experience, identifying effective and synergistic interventions can present a challenge, especially in the setting of limited ED resources. Utilizing the themes identified in a recent systematic review of the ED patient experience literature, we developed a conceptual “logic model” of ED patient experience in order to provide a broadly applicable framework for practical intervention and to guide further study of ED patient experience interventions. The logic model was modified in an iterative fashion through review by local patient and staff groups as well as a national interest group until arriving at the current, comprehensive version. Here, we describe the creation of the logic model and, with the aim of providing a framework for readers to develop similar models for their practice settings, provide a case discussion of its use by an ED medical director.