Emergency Department Administration Research Articles

Psychotropic Medication Administration in Pediatric Emergency Departments.

Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals. We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital. Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001). Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.

Emergency Department Access to Buprenorphine for Opioid Use Disorder

Although substantial evidence supports buprenorphine for treatment of opioid use disorder (OUD) in controlled trials, prospective study of patient outcomes in clinical implementation of emergency department (ED) buprenorphine treatment is lacking. To examine the association between buprenorphine treatment in the ED and follow-up engagement in OUD treatment 1 month later. This multisite cohort study was conducted in 7 California EDs participating in a statewide implementation project to improve access to buprenorphine treatment. The study population included ED patients aged at least 18 years identified with OUD between April 1, 2021, and June 30, 2022. Data analysis was performed in October 2023. All participants were offered buprenorphine treatment for OUD (either in ED administration, prescription, or both), the uptake of which was examined as the exposure of interest. The primary outcome was engagement in OUD treatment 30 days after the ED visit, determined by patient report or clinical documentation. The association of ED buprenorphine treatment with subsequent OUD treatment engagement was estimated using hierarchical generalized linear models. This analysis included 464 ED patients with OUD. Their median age was 36.0 (IQR, 29.0-38.7) years, and most were men (343 [73.9%]). With regard to race and ethnicity, 64 patients (13.8%) self-identified as non-Hispanic Black, 183 (39.4%) as Hispanic, and 185 as non-Hispanic White (39.9%). Most patients (396 [85.3%]) had Medicaid insurance, and more than half (262 [57.8%]) had unstable housing. Self-reported fentanyl use (242 [52.2%]) and a comorbid mental health condition (328 [71.5%]) were common. Interest in buprenorphine treatment was high: 398 patients (85.8%) received buprenorphine treatment; 269 (58.0%) were administered buprenorphine in the ED and 339 (73.1%) were prescribed buprenorphine. With regard to OUD treatment engagement at 30 days after the ED visit, 198 participants (49.7%) who received ED buprenorphine treatment remained engaged compared with 15 participants (22.7%) who did not receive ED buprenorphine treatment. An association of ED buprenorphine treatment with subsequent OUD treatment engagement at 30 days was observed (adjusted risk ratio, 1.97 [95% CI, 1.27-3.07]). The findings of this cohort study suggest that among patients with OUD presenting to EDs implementing low-threshold access to medications for OUD, buprenorphine treatment was associated with a substantially higher likelihood of follow-up treatment engagement 1 month later. Future research should investigate techniques to optimize both the uptake and effectiveness of buprenorphine initiation in low-threshold settings such as the ED.

Epinephrine in Cardiac Arrest: Identifying a Potential Limit for Resuscitation.

Epinephrine continues to be a fundamental part of the Advanced Cardiac Life Support algorithm despite a lack of evidence that it improves neurologically intact survival. Our aim was both to identify a potential upper limit of epinephrine use in resuscitations and to demonstrate real-world epinephrine use in different patient subgroups. This was a single-center, retrospective cohort study, conducted between August 1, 2016-July 1, 2021, of patients with medical cardiac arrest who were administered a known number of epinephrine doses. The primary outcome was neurologically intact discharge defined by a modified Rankin scale ≤3, with secondary outcomes of comparing epinephrine doses by age, rhythm, and emergency medical services vs emergency department administration of epinephrine. The study included 1,330 patients, with 184 patients (13.8%) surviving to neurologically intact discharge. The primary outcome of neurologically intact discharge was found in 89 (65.4%) patients in the zero epinephrine dose group, 75 (20.0%) in the 1-3 dose group, 15 (4.3%) in the 4-6 dose group, and one (0.002%) in the ≥7 dose group (P < 0.001). Patients received similar amounts of epinephrine when stratified by age, while patients with shockable rhythms received more epinephrine than patients with non-shockable rhythms. There was a significant decrease in neurologically intact discharge with increasing number of epinephrine doses, and our data suggests that seven or more doses of epinephrine is almost always futile. While further prospective studies are needed, clinicians should consider epinephrine doses when weighing the futility or benefit of continued resuscitation efforts.

190 Health Disparities in Emergency Department Administration of Buprenorphine for Treatment of Opioid Use Disorder

190 Health Disparities in Emergency Department Administration of Buprenorphine for Treatment of Opioid Use Disorder

Decompensated metabolic acidosis in the emergency department: Epidemiology, sodium bicarbonate therapy, and clinical outcomes

ObjectiveThis article aims to describe the epidemiology of decompensated metabolic acidosis, the characteristics of sodium bicarbonate (SB) administration and outcomes in emergency department (ED) patients. DesignThis is a retrospective cohort study. SettingED of a tertiary referral hospital in Melbourne, Australia. ParticipantsAdult patients presenting to the ED between 1 July 2011 and 20 September 2020 with decompensated metabolic acidosis diagnosed on arterial blood gas (ABG). Main outcome measuresWe compared characteristics between those treated with or without SB. We studied SB administration characteristics, change in laboratory variables, factors associated with use and dose, and clinical outcomes. ResultsAmong 753,613 ED patients, 314 had decompensated metabolic acidosis on ABG, with 17.8% receiving SB. Patients in the SB group had lower median pH, CO2, bicarbonate, and base excess (BE) levels compared with the No SB group (P < 0.01). The median number of SB doses in the SB group was one treatment. This was given at a median total dose of 100 mmol and at a median of 2.8 h after the diagnostic blood gas results. Only 42% of patients in the SB group had a subsequent blood gas measured. In such patients, there was no significant change in pH, bicarbonate, or BE. SB therapy was not independently associated with mortality. ConclusionsABG-confirmed decompensated metabolic acidosis was rare but associated with a high mortality. SB administration occurred in a minority of patients and in more acidaemic patients. However, SB dose was stereotypical and not tailored to acidosis severity. Assessment of SB effect was infrequent and showed no correction of acidosis. Systematic studies of titrated SB therapy are required to inform current practice.

Edmonton Zone triage project (EZ Triage)

Background: Canadian Emergency Departments (ED) use the five-point Canadian Triage Acuity Scale (CTAS) to prioritize patients according to acuity. CTAS scores are used to make decisions on patient flow, staffing complement, and funding. Variations in triage can lead to mis-categorization and delayed care for critically ill patients. Edmonton zone quality improvement audits reduced high and low-risk vital sign errors (86% and 78%, respectively), increased between-nurse triage consistency, and levelled triage burden for individual nurses. However, previous audits were time-consuming and required auditors with clinical, data management, and analysis expertise, preventing their wide-scale adoption.&#x0D; &#x0D; Implementation: This project utilizes the AHS AIW implementation framework. It is the extension of a triage audit and feedback tool that was developed and validated over a three-year window (Cotton et al., 2021). This current project is a scaling-up of the QI audit framework to a Tableau dashboard that will allow ED administrators and educators to efficiently examine individual nurse-level and department triage variation to craft local QI measures to improve triage accuracy.&#x0D; &#x0D; The newly developed QI tool uses raw EPIC data retrieved from AHS data warehouses. It translates the framework to a python script that duplicates existing Excel QI framework Boolean logic and generates binary output variables. These variables are then loaded into a preformatted Tableau dashboard that displays both department and nurse-level triage variances (trimmed mean and standard deviation) for the following variables: high and low acuity vital sign error rates, triage acuity overrides, and sepsis alerts. The dashboard data (and visualizations) allow users to filter errors by nurse and error type. They include all the relevant triage-associated data and can be used for near real-time monitoring of triage variances or downloaded for additional department-level analyses.&#x0D; &#x0D; Patient and Family Engagement: Triage has consistently been identified as an area of concern for hospital administrators, clinicians, and patients. Most complaints received by hospitals about ED care are generated at triage. Literature has suggested that triage can be cognitively demanding for nurses, and data have suggested that patients have experienced bias during triage. This project will benefit patients by minimizing errors, ensuring consistent triage, and allowing other sites across the province to engage in similar QI efforts. Because these triage QI efforts require the review of patient-sensitive data, patients were not included in the analyses. &#x0D; &#x0D; Evaluation Methods: The output of the triage audit dashboard was assessed in two ways: by soliciting the feedback of clinical audit end-users on the ease of use and operability of the dashboard, and by assessing the reliability of the tool by comparing it to the existing definitions and standard of screening.&#x0D; &#x0D; The user interface of the triage audit system was assessed and refined soliciting feedback from end-users of the system. Each refinement cycle was accompanied by further feedback. A random 10,000-patient sample was used to perform assess the performance of the tool. The reliability of the dashboard was calculated by the sensitivity, specificity, accuracy, and agreement of expert raters. Between-group comparisons of expert and automated systems to gold-standard manual reviews were performed using Cohen’s Kappa.&#x0D; &#x0D; Results: Feedback was collected from two emergency departments. Refinement cycles resulted in a dashboard that allows decision-makers to compare practice at a nursing level while offering near-real-time feedback and access to patient visit-level data. Feedback resulted in the addition of Systemic Inflammatory Response Syndrome (SIRS) related errors to the model. There were 10,000 patient visits considered for analysis. Patients less than 18 years of age (3%, n=306 visits) and visits with incomplete data (n=86) were removed. The final sample was 9608 visits.&#x0D; &#x0D; Four categories of error were assessed: High-acuity, low-acuity, pain, and SIRS-criteria. Automated screening of high and low acuity errors had 100% sensitivity, specificity, and accuracy (κ =1, p&lt;0.001) and outperformed expert review for high-risk (sensitive=97.8%, specificity=100%, accuracy=99.98%; κ =0.989, p,0.001) and low-risk errors (sensitivity=98.9%, specificity=100%, accuracy=99.98%; κ =0.994, p,0.001) compared to gold-standard expert manual review. Computer screening outperformed (sensitivity=71.3%, specificity=96.7%, accuracy=96.27%; κ =0.39, p,0.001) compared to expert assessment for pain errors (sensitivity=52.0%, specificity=97.4%, accuracy=96.58%; κ =0.335, p&lt;0.001). Expert screening (sensitivity=100%, specificity=99.9%, accuracy=99.9%; κ =0.962, p&lt;0.001); outperformed computer screening (sensitivity=7.9%, specificity=100%, accuracy=98.91%; κ =0.145, p&lt;0.001) for SIRS-related errors. &#x0D; &#x0D; Advice and Lessons Learned:&#x0D; &#x0D; Maintaining data integrity for the dashboard required multiple rounds of feedback and clinician input.&#x0D; Because of the small sample and subsequent exclusion of pediatric patients the current dashboard and error detections thresholds levels for pediatric vital sign modifiers will need further validation before being used for pediatric ED patients.&#x0D; Further refinements to the tool are needed to incorporate previously used text-parsing algorithms into the detection of pain-related triage errors.&#x0D;

A Nationwide Survey and System Analysis of Emergency Triage System in Lao People's Democratic Republic

Objective: To assess the present status of the emergency department (ED) triage system in 162 hospitals across the Lao People's Democratic Republic (Lao PDR). Materials and Methods: The Lao PDR nationwide survey participants recruited ED administrators. The EDs were randomly recruited. The standard questionnaire package was used for data collection including patients’ demographics and triage systemic factors. Descriptive analysis was applied to analysis the outcome of interest. Results: A majority of triage officers were emergency room nurses (58.6%), general physicians (20.4%), or both (11.1%). Most hospitals (89.5%) used informal triage scales such as clinical experiences or colors to prioritize ED patients. Only 17 hospitals (10.5%) had a formal triage scale in their ED care systems and used it in their practice. Conclusion: These findings provide knowledge of the ED triage system in the Lao PDR. The results indicate that the Lao PDR lacks a formal ED triage scale but uses a variety of informal scales. Thus, it is necessary to set up a standard triage system at all hospitals to standardize ED healthcare across the country.

Acil Serviste Trombolitik Uygulanan Hastaların Özellikleri

Objective: Arterial and venous thromboembolism is one of the most prevalent diseases and related to ischemic stroke, pulmonary embolism, and myocardial infarction leading to mortality or morbidity. Fibrinolytic therapy is the most profound lifesaving therapy in these diseases. We aimed to evaluate the demographic features and post- tissue plasminogen activator (tPA) period of patients administered fibrinolytic in the emergency department (ED). Materials and Methods: This retrospective study was conducted with patients instituted fibrinolytic therapy in the ED between January 2018 and July 2021. Age and gender of the patients, vital signs, laboratory tests, comorbidities, drugs used, lifesaving therapies secondary to the present pathology, tPA complications, mortality and similar presentations within the six months period were recorded to the study form. Results: A total of 277 patients were included into the study. Ischemic stroke was the most prevalent disease entailing the institution of tPA (n=252; 91%). The study patients mostly used antihypertensives (n=155, 56%), followed by anti-aggregants (n=101, 36.5%). Intracranial hemorrhage (11.9%) was the most frequent complication secondary to tPA and the study patients had mostly undergone thrombectomy as a lifesaving therapy (n=34, 12.4%). The univariate analysis revealed that antiaggregant usage (n=21, 53.8% vs n=80, 33.6%; p=0.01), systolic blood pressure (160 mmHg, IQR: 138-190 vs 150 mmHg 130-169; p=0.02) and diastolic blood pressure (90 mmHg, IQR: 75-100 vs 83 mmHg, IQR: 72-94; p=0.03) differ between the patients with and without a post-tPA hemorrhage. Conclusion: According to the results of this study, ischemic stroke is the main pathology related to tPA administration in ED. Hypertension was the most seen comorbidity in study patients, mostly using anti-hypertensive and anti-aggregants. Intracranial hemorrhage was the most prevalent complication owing to tPA use, and systolic and diastolic blood pressures and anti-aggregant use pertain to post-tPA hemorrhages.

Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Variation in Emergency Department Use of Racemic Epinephrine and Associated Outcomes for Croup.

Racemic epinephrine (RE) is commonly administered for croup in the emergency department (ED). Our objectives were to examine variation in RE use between EDs, to determine whether ED variation in RE use is associated with hospital or patient factors, and to evaluate the associations between the rates of hospital-specific ED RE use and patient outcomes. We performed a retrospective cohort study using the Pediatric Heath Information System of children aged 3 months to 10 years with croup in the ED. We used mixed-effects regression to calculate risk-standardized proportions of patients receiving RE in each ED and to analyze the relationship between risk-standardized institutional RE use and individual patient odds of hospital admission, ICU admission, and ED revisits. We analyzed 231 683 patient visits from 39 hospitals. ED administration of RE varied from 14% to 48% of visits (median, 24.5%; interquartile range, 20.0%-27.8%). A total of 8.6% of patients were hospitalized and 1% were admitted to the ICU. After standardizing for case mix and site effects, increasing ED use of RE per site was associated with increasing patient odds of hospital admission (odds ratio [OR], 1.39-95%; confidence interval [CI], 1.01-1.91), but not ICU admission (OR, 1.39; 95% CI, 0.99-1.97) or ED revisit (OR, 1.00; 95% CI, 0.92-1.09). In this large, observational study, RE administration varied widely across EDs. Increased RE use by site was associated with increased odds of hospital admission for individual patients when controlling for patient factors. These results suggest further standardization of RE use in children with croup is warranted.

Emergency Medicine Residents' Perceptions of Working and Training in a Pandemic Epicenter: A Qualitative Analysis.

We sought to describe the range of emergency medicine (EM) resident physicians' perceptions and experiences of working and training during the initial coronavirus 2019 (COVID-19) pandemic surge at two, large-volume, urban training hospitals in Brooklyn, New York. A total of 25 EM resident physicians who worked at either of two large emergency departments (ED) from March 15-April 11, 2020 participated in semi-structured interviews conducted in July and August 2020. Interviews were conducted by the authors who were also emergency medicine resident physicians working in the ED during this time. We asked open-ended questions to residents about their experiences and emotions at work and outside of work, including their relationship with co-workers, patients, and their community. The interviews were audio-recorded and transcribed. We then conducted a thematic analysis to identify, classify, and define themes from interview transcripts. Iterative commonalities and differences between interview response themes were grouped to create a broadly applicable narrative of the residents' perceptions and experiences of working and training during this initial wave of a novel pandemic. Interviewees also responded to a demographics survey. Study participants described four major aspects of their perceptions and experiences of working and training during the stated time, including emotional challenges such as anxiety and feeling underappreciated; protective thoughts, including camaraderie, and sense of duty; workplace challenges such as limited knowledge surrounding COVID-19 and a higher volume of acute patients; and adaptive strategies including increased communication with ED administrators. Emergency medicine residents have a unique perspective and were key frontline hospital responders during a prolonged disaster and mass triage event within a local health system. Considering the chronic case and mortality fluctuations and new variants of COVID-19, as well as the anticipation of future infectious disease pandemics, we believe it is important for key decision-makers in resident education, hospital administration, and all levels of public health management to inform themselves about residents' emotional and workplace challenges when establishing hospital and residency program disaster protocols.

A Qualitative Study of Emergency Department Delirium Prevention Initiatives.

Delirium is a serious but preventable syndrome of acute brain failure. It affects 15% of patients presenting to emergency care and up to half of hospitalized patients. The emergency department (ED) often represents the entry point for hospital care for older adults and as such is an important site for delirium prevention. We sought to characterize delirium prevention initiatives in EDs in the United States and Canada. We conducted qualitative interviews with 16 ED administrators representing 14 EDs with delirium prevention initiatives. We used a combined deductive-inductive approach to code responses about involved staff, target patient population, and delirium prevention activities. ED delirium prevention initiatives were largely driven by bedside nurses and occurred on an ad hoc basis, rather than systematically. Due to resource limitations, three EDs targeted older adults with high-risk conditions for delirium, rather than all patients age 65 and over. The most common delirium prevention interventions were offering assistive sensory devices (hearing amplifiers, reading glasses), having a toileting protocol, and offering patients food and drink. As minimal evidence exists about effective ED delirium prevention practices, low-cost and low-risk activities outlined by study participants are reasonable to use to improve patient experience and staff satisfaction.

Racial Disparities in Opioid Analgesia Administration Among Adult Emergency Department Patients with Abdominal Pain.

Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients' self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States. This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019-December 31, 2020. We collected demographic and clinical information, including patients' race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient's race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival. We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival. Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.

343EMF Identifying and Addressing Barriers to Emergency Department Buprenorphine Use Across a Health Care System

343EMF Identifying and Addressing Barriers to Emergency Department Buprenorphine Use Across a Health Care System

348 Differences in Antipsychotic and Sedative Administration in Community vs Academic Emergency Departments Across a Health System

Antipsychotic and sedative medications are commonly used in the emergency department (ED) for a variety of reasons, including procedural sedation and treatment of agitation. Administration of these medications in older adults may result in harm, including increased risk of delirium and falls, but knowledge of practice patterns of administration of these medications to older adults in the ED is limited. The purpose of this study is to characterize the use of parenteral antipsychotic and sedative medications in geriatric patients in the ED and compare utilization at academic and community sites.

Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study

ObjectiveWhether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use.MethodsParticipants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use (e.g., opioids without prescription or taking more than prescribed for euphoria) in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months.ResultsOf 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620 (5.3%, CI: 3.7,7.4) participants without ED opioid analgesic exposure; 4/16 (25.0%, CI: 8.3, 52.6) with ED opioid prescription only; 17/146 (11.6%, CI: 7.1, 18.3) with ED opioid administration only; 12/90 (13.3%, CI: 7.4, 22.5) with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 (95% CI 1.4, 17.4); ED administration for analgesia only: 2.0 (CI 1.0, 3.8); both: 2.8 (CI 1.2, 6.5).ConclusionsED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making.

Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol

IntroductionCOVID-19 required healthcare systems to iteratively adapt for safe and up-to-date care as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate and patients without COVID-19...

Practice Patterns and Assessment of Needs for Pediatric Pain Management in Alberta Emergency Departments.

PurposeMany rural and community emergency departments (EDs) experience barriers to providing optimal pain care to children. In preparation for a quality improvement initiative, our team conducted a provincial pediatric pain management practice and needs assessment.MethodsAn online survey was sent to ED administrators and educators from March to May 2017. Themes included pain assessment, pain and distress management strategies, available resources, education, barriers to care, and opportunities for improvement.ResultsForty-five respondents, from 31 EDs representing all five geographic health zones in Alberta, completed the survey. Use of a pain assessment tool was reported at 93.5% (29/31 sites) of the sites. Topical anesthesia was employed “most of the time” before suturing at 67% (18/27) of sites, versus 15% (4/27) before blood work or IV insertion. Eighty-one percent (22/27) of sites reported physically restraining children for procedures “often”, while 37% (10/27) reported use of comfort positioning “often”. Digital distraction devices were available at 37% (10/27) of sites. Reported challenges included lack of resources (33.3%, 12/36), staff education/knowledge (33.3%, 12/36), and absent policies/poor policy adherence (25.0%, 9/36). Opportunities for improvement included staff member education (73.5%, 25/34) and more resources (58.8%, 20/34). Respondents rated their site’s overall ability to manage children’s pain as 50/100 [IQR:21,61].ConclusionGeneral EDs report providing suboptimal children’s pain care, with use of physical restraint for medical procedures, and under-utilization of evidence-based, inexpensive treatment options. There are many gaps in children’s pain care in rural and community EDs which could be addressed through collaborative quality improvement initiatives.

Diltiazem Dosing Strategies in the Management of Atrial Fibrillation With Rapid Ventricular Rate.

IntroductionDiltiazem is commonly used for the management of atrial fibrillation (AFIB) with rapid ventricular rate (RVR) in the emergency department (ED). Conflicting studies comparing the efficacy of diltiazem have led to various dosing strategies. The objective of this study was to investigate diltiazem administration in a community ED and determine the effect of varying doses on heart rate (HR) control, systolic blood pressure (SBP) and diastolic blood pressure (DBP).MethodsThis is a retrospective, single-center study of adult patients treated with diltiazem for AFIB-RVR in the ED between January 1 and December 31, 2019. Inclusion criteria included pretreatment HR > 120 beats per minute (bpm). Patients were administered diltiazem at the discretion of the ED physician. Primary endpoint was time to achieve HR < 100 bpm after diltiazem. Secondary endpoints included mean weight-based dose of diltiazem, percentage of patients achieving HR < 100 bpm within 240 minutes of diltiazem, nadir SBP and nadir DBP.ResultsNinety-nine patients were included in the study. Seventy-two percent of patients received ≤ 10 mg diltiazem bolus. Mean weight-based dose of diltiazem bolus was 0.13 mg/kg. Mean time to achieve HR < 100 bpm was 270 minutes for the entire cohort. Patients treated with ≥ 0.13 mg/kg diltiazem achieved an HR < 100 bpm at a mean time of 169 minutes compared to 318 minutes for < 0.13 mg/kg (p = 0.0107). HR control was achieved in 61% of patients who received ≥ 0.13 mg/kg compared to 36% of patients who received < 0.13 mg/kg diltiazem (p = 0.0213). No patients discontinued diltiazem for hypotension or bradycardia. The lowest recorded SBP and DBP within 240 minutes of diltiazem were 90 mmHg and 47 mmHg, respectively. There was no significant difference in the lowest SBP and DBP for patients who received < 0.13 mg/kg compared to ≥ 0.13 mg/mg diltiazem.ConclusionThe majority of patients with AFIB RVR received a 10 mg non-weight-based diltiazem bolus dose in the ED. Diltiazem bolus dosing ≥ 0.13 mg/kg was associated with significantly improved times to achieve HR control compared to < 0.13 mg/kg and was not associated with hypotension or bradycardia.

264 Racial Inequities in Emergency Department Administration of Buprenorphine and Methadone Among Patients With Opioid Use Disorder

The COVID-19 pandemic has exacerbated longstanding inequities in opioid use disorder (OUD) that reflect multiple facets of structural racism. In Massachusetts, opioid overdose deaths in 2020 rose by nearly 70% in Black men compared to just 5% overall. Emergency department (ED) visits in people with OUD may represent key touchpoints for overdose prevention. Although racial inequities in buprenorphine and methadone maintenance initiation, dosing, and retention have been well documented, less is known about the administration of medications for opioid use disorder (MOUD, buprenorphine and methadone), in the ED. ED leadership initiated an internal review to explore racial equity in multiple clinical quality metrics, including frequency of MOUD administration in patients with OUD. Retrospective data were analyzed for quality improvement (QI) purposes. Patients presenting to the ED with OUD July 29, 2020-March 12, 2021 were identified via ICD-10 codes. Patient demographics and MOUD administration were explored using descriptive statistics; c2 tests compared the frequency of MOUD administration by race. An intensive QI intervention to improve MOUD utilization will be delivered to all ED prescribers in June 2021. The intervention includes content on racial inequities in OUD treatment and factors that drive them, including provider bias, reasons for mistrust of the medical system among patients of color, and structural barriers to OUD treatment and retention. Through educational sessions for providers, transparency of data of current MOUD trends in the ED, and structured on-shift reminders by ED pharmacists, we plan to improve provider-patient communication and MOUD utilization in the ED. The QI initiative will be followed by a three-month monitoring period (July-September 2021) to evaluate for changes in MOUD administration. A total of 998 unique patients with OUD were seen for 1452 ED visits. Documented race was 56.7% White, 21.5% Black, 13.5% Hispanic, 1.7% Other, and 6.6% unknown. MOUD were administered during 945/1452 visits (65.1%). The likelihood of administration varied significantly by race: 80.3% of White patients received MOUD compared to 35.9% of Black patients, and 59.9% of Hispanic patients (p<0.001, Table 1). Significant differences in treatment were also observed when comparing white and Black patients (p<0.001) and white and Hispanic patients (p<0.001) directly. Renewed attention to ensuring racial equity in clinical practice prompted an exploration of ED data at our institution, including equitable administration of buprenorphine and methadone in patients with OUD. This QI analysis identified a racial inequity, prompting the development of a QI initiative to improve overall utilization of MOUD, with a specific focus on mitigating observed racial inequities. Data analysis from the post-QI intervention period will be completed prior to presentation at ACEP.