Emergency Department Attendances Research Articles

Examining the hospital costs of children born into relative deprivation in England

ObjectiveTo examine the association between being born into relative deprivation and hospital costs during childhood.DesignRetrospective cohort study.MethodsWe created a birth cohort using Hospital Episode Statistics for children born in NHS...

Association between emergency department attendances, sociodemographic factors and long-term health conditions in the population of Norfolk and Waveney, England: Cross sectional study.

Demand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals' characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England. The study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual's sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models. 1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15-35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)). In the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.

Emergency department pediatric mental and behavioral health patients transported by EMS and police: Trends and interventions

ObjectiveWe aimed to understand transport utilization trends, demographics, Emergency Department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported. MethodsThis retrospective cohort study utilized electronic health record data from patients aged 5-18 years presenting with acute MBH conditions at two affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using Chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends. ResultsOf 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% CI [0.7, 1.7], p = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], p = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores, and to be admitted compared to self-transported patients (all comparisons p < 0.001). ConclusionsPediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management. What’s NewWith higher numbers of pediatric mental and behavioral health (MBH) patients transported by EMS or police requiring ED interventions for agitation/aggression, this study reveals insights into their high-acuity. Notably unique, it includes pediatric MBH patients transported by police.

Clinical epidemiology and outcomes of emergency department-acute kidney injury: A systematic review

BackgroundOver half of all community-acquired acute kidney injury (CA-AKI) initially presented to emergency department (ED), but emergency department acute kidney injury (ED-AKI) is poorly characterised, poorly understood with no systematic review, often under-recognized and under-managed. ObjectiveTo review the incidence, risk factors, and outcomes of ED-AKI, and risk factors of post-ED-AKI mortality globally. MethodsWe included published prospective or retrospective observational studies, controlled trials, and systematic reviews reporting AKI in adult ED attendees within 24 h of ED admission. Iatrogenic causes of AKI from medical interventions were excluded. We used PubMed to identify articles from 1996 to August 14, 2021, and adopted the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to assess risk of bias. We used a Forest plot to present pooled ED-AKI incidence rates and I2 statistics. Other parameters were summarized narratively. ResultsUsing 24 h from ED admission as the definition for ED-AKI we identified six articles from 2005 to 2018 in high-income settings and one article with a 48-h timeframe. The pooled incidence of ED-AKI was 20 per 1000 adult ED attendances. Risk factors for ED-AKI included increasing age, nursing home residence, previous hospital admission within 30 days, discharge diagnosis of diabetes, obstructive uropathy, sepsis, gastrointestinal medical conditions, high serum creatinine, bilirubin, C-reactive protein, white blood cell, alanine aminotransferase, low serum sodium or albumin on admission, poor premorbid renal function, antibiotic use, active malignancy, lung disease, hyperlipidaemia, and infection. Crude, all-cause 24-h mortality rate was 4.56 % and the one-year mortality rate was 35.04 %. Increasing age and comorbidities including cardiovascular disease and malignancy were associated with higher mortality rates. ConclusionThe review reveals a paucity of relevant literature which calls for further research, increased vigilance, red flag identification, and standardized management protocols for ED-AKI.

CAN REFERRAL TO COMMUNITY-BASED EXERCISE PHYSIOLOGIST SERVICES REDUCE EMERGENCY DEPARTMENT BURDEN? A CHART AUDIT

INTRODUCTION &amp; AIMS Despite the rapid growth of exercise physiology in Australia, its potential within the healthcare system remains underutilised. Healthcare system strain, characterised by increased emergency department (ED) waiting times and length-of-stay is exacerbated by preventable, non-urgent ED attendances. In 2022, musculoskeletal conditions constituted the majority of &amp;gt;800,000 non-urgent ED presentations. Community care and underutilised allied health services, such as exercise physiology, may offer better management options. This study aimed to examine characteristics of patients presenting to ED for musculoskeletal conditions, treatment advice provided on physical activity, and referral practices to community-based exercise physiology services. METHODS A retrospective chart audit (n=267) examined patient characteristics, referral patterns and treatment advice due to non-urgent musculoskeletal conditions at Eastern Health EDs. RESULTS Most (n=223, 84%) patients presented with conditions that had persisted for a mean (SD) duration of 9.3 (32.4) days. Conditions affecting the leg (n=92, 34%), lower back (n=59, 22%) and arm (n=44, 16%) were most common. Sharp pain was the most common descriptor of pain (n=33, 12%). Almost half (45%, n=119) had comorbid cardiovascular disease (n=59, 22%), metabolic conditions (n=31, 12%) or mental health issues (n=29, 11%). Treatment advice on physical activity was provided for 17% to patients with 12% advised to avoid physical activity (n=31, 12%) and 5% to stay active (n=12). Advice to return to (n=2, 1%) or take time off (n=47, 18%) work was provided for 19% (n=49) patients. No patients were referred to exercise physiology services. CONCLUSION Patients presenting to EDs for musculoskeletal conditions appeared suitable for referral to community-based exercise physiology services, yet no referrals were identified. Moreover, few patients received advice on whether to stay active or avoid physical activity. Strategies to increase external ED referral to exercise physiology are warranted to alleviate burden within this setting.

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition.

The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition. This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay. A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients. Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.

Emergency Department-Based Physical Function Measures for Falls in Older Adults and Outcomes: A Secondary Analysis of GAPcare.

Falls are the leading reason for injury-related emergency department (ED) visits for older adults. The Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), an in-ED intervention combining a medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist, reduced ED revisits at 6 months among older adults presenting after a fall. Our objective was to evaluate the relationship between measures of function obtained in the ED and clinical outcomes. This was a secondary analysis of data from GAPcare, a randomized controlled trial conducted from January 2018 to October 2019 at 2 urban academic EDs. Standardized measures of function (Timed Up and Go [TUG] test, Barthel Activity of Daily Living [ADL], Activity Measure for Post Acute Care [AM-PAC] 6 clicks) were collected at the ED index visit. We performed a descriptive analysis and hypothesis testing (chi square test and analysis of variance) to assess the relationship of functional measures with outcomes (ED disposition, ED revisits for falls, and place of residence at 6 months). Emergency department disposition status refers to discharge location immediately after the ED evaluation is complete (eg, hospital admission, original residence, skilled nursing facility). Among 110 participants, 55 were randomized to the GAPcare intervention and 55 received usual care. Of those randomized to the intervention, 46 received physical therapy consultation. Median age was 81 years; participants were predominantly women (67%) and White (94%). Seventy-three (66%) were discharged to their original residence, 14 (13%) were discharged to a skilled nursing facility and 22 (20%) were admitted. There was no difference in ED disposition status by index visit Barthel ADLs (P = .371); however, TUG times were faster (P = .016), and AM-PAC 6 clicks score was higher among participants discharged to their original residence (P ≤ .001). Participants with slower TUG times at the index ED visit were more likely to reside in nursing homes by six months (P = .002), while Barthel ADL and AM-PAC 6 clicks did not differ between those residing at home and other settings. Measures of function collected at the index ED visit, such as the AM-PAC 6 clicks and TUG time, may be helpful at predicting clinical outcomes for older adults presenting for a fall. Based on our study findings, we suggest a novel workflow to guide the use of these clinical measures for ED patients with falls.

An ensemble model for predicting dispositions of emergency department patients

ObjectiveThe healthcare challenge driven by an aging population and rising demand is one of the most pressing issues leading to emergency department (ED) overcrowding. An emerging solution lies in machine learning’s potential to predict ED dispositions, thus leading to promising substantial benefits. This study’s objective is to create a predictive model for ED patient dispositions by employing ensemble learning. It harnesses diverse data types, including structured and unstructured information gathered during ED visits to address the evolving needs of localized healthcare systems.MethodsIn this cross-sectional study, 80,073 ED patient records were amassed from a major southern Taiwan hospital in 2018–2019. An ensemble model incorporated structured (demographics, vital signs) and pre-processed unstructured data (chief complaints, preliminary diagnoses) using bag-of-words (BOW) and term frequency-inverse document frequency (TF-IDF). Two random forest base-learners for structured and unstructured data were employed and then complemented by a multi-layer perceptron meta-learner.ResultsThe ensemble model demonstrates strong predictive performance for ED dispositions, achieving an area under the receiver operating characteristic curve of 0.94. The models based on unstructured data encoded with BOW and TF-IDF yield similar performance results. Among the structured features, the top five most crucial factors are age, pulse rate, systolic blood pressure, temperature, and acuity level. In contrast, the top five most important unstructured features are pneumonia, fracture, failure, suspect, and sepsis.ConclusionsFindings indicate that utilizing ensemble learning with a blend of structured and unstructured data proves to be a predictive method for determining ED dispositions.

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits.

Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year. This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region. Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020. Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.

Health service use of infants involved in family justice care and supervision proceedings in Wales: a data linkage study

IntroductionWhen a child has suffered, or is at risk of suffering, significant harm from parents or caregivers, the local authority may issue Section 31 (s.31) Care and Supervision proceedings under the Children Act (1989). ObjectivesWe compared the healthcare use of infants less than one year old subject to s.31 proceedings in Wales (n = 1,332),to that of a comparison group of infants not subject to s.31 proceedings (n = 204,417), between January 2011 and February 2020. MethodsPopulation-based e-cohort study utilising data held in the Secure Anonymised Information Linkage (SAIL) Databank. Infants in s.31 proceedings were identified using the Children and Family Court Advisory and Support Service dataset. This was linked to demographic and healthcare datasets, to identify General Practice (GP) visits, emergency department (ED) attendances, and hospital admissions (emergency and elective); before the study end date or the child's first birthday for the comparison group, orbefore the s.31 application date.Regression analysis calculated event rate ratios [RR] and incidence rate ratios [IRR] for healthcare events, adjusting for widerdeterminants of health (e.g. perinatal factors, maternal mental health, deprivation), and investigated reasons for healthcare use. ResultsInfants in s.31 proceedings had ahigher number and incidence of healthcare events compared with the comparison group, across all healthcare settings. Differences were greatest for emergency hospital admissions (IRR = 4.03, 95% confidence interval [CI] = 3.53 - 4.59; RR = 4.60, CI = 3.90 - 5.41). "Injury and poisoning" was the main reason for emergency admissions amongst infants in s.31 proceedings. For ED presentations, emergency hospital admissions, and GP visits, there were proportionally more events for these infants across all top ten reasons for healthcare. ConclusionsFindings highlight greater healthcare utilisation for infants involved in s.31 proceedings in Wales, helping to build a better understanding of their needs and vulnerabilities.

A systematic review of reasons and risks for acute service use by older adult residents of long-term care.

To identify the reasons and/or risk factors for hospital admission and/or emergency department attendance for older (≥60 years) residents of long-term care facilities. Older adults' use of acute services is associated with significant financial and social costs. A global understanding of the reasons for the use of acute services may allow for early identification and intervention, avoid clinical deterioration, reduce the demand for health services and improve quality of life. Systematic review registered in PROSPERO (CRD42022326964) and reported following PRISMA guidelines. The search strategy was developed in consultation with an academic librarian. The strategy used MeSH terms and relevant keywords. Articles published since 2017 in English were eligible for inclusion. CINAHL, MEDLINE, Scopus and Web of Science Core Collection were searched (11/08/22). Title, abstract, and full texts were screened against the inclusion/exclusion criteria; data extraction was performed two blinded reviewers. Quality of evidence was assessed using the NewCastle Ottawa Scale (NOS). Thirty-nine articles were eligible and included in this review; included research was assessed as high-quality with a low risk of bias. Hospital admission was reported as most likely to occur during the first year of residence in long-term care. Respiratory and cardiovascular diagnoses were frequently associated with acute services use. Frailty, hypotensive medications, falls and inadequate nutrition were associated with unplanned service use. Modifiable risks have been identified that may act as a trigger for assessment and be amenable to early intervention. Coordinated intervention may have significant individual, social and economic benefits. This review has identified several modifiable reasons for acute service use by older adults. Early and coordinated intervention may reduce the risk of hospital admission and/or emergency department. This systematic review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. No patient or public contribution.

Changes in alcohol-related emergency department presentations—a comparison of three waves in 2013, 2017 and 2022

aims: Emergency departments (EDs) around the world are increasingly overcrowded, which is associated with significant patient harm. Alcohol use is a known contributor to ED overcrowding. This study aimed to assess trends in the characteristics of alcohol-related ED presentations over time. methods: A cross-sectional observational study of Christchurch ED attendances during 3-week waves of data collection in November–December 2013, 2017 and 2022 was conducted. Potential participants were those patients attending the Christchurch Hospital ED who had ingested alcohol in the 4 hours prior to arrival, and/or the presentation was thought to be related to alcohol. Those who consented to take part were interviewed to examine amount and source of alcohol. results: There has been a change in the age profile towards a greater proportion of older patients attending the ED with alcohol-related issues. In 2022, a greater proportion of alcohol was purchased from on-licence venues compared to previous years, although off-licence alcohol purchase and consumption in private locations remained the most common. conclusion: Alcohol use and harm places a significant, yet preventable, burden on EDs and the wider healthcare system. Implementation of evidence-based alcohol policies is urgently needed to reduce the impact of alcohol in the ED and improve the health of communities.

Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A TRACK-TBI Study.

Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 hours (h) of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants aged ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; 1 additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared to without (median: 630.6 pg/ml, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p=0.049), and were associated with axonal injury (no: median 226.7 pg/ml [109.6-435.1], yes: 828.6 pg/ml [204.0-1194.3], p=0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our modest sample size and await validation from larger studies.

Clinical outcomes for sexual and gender minority adolescents in a dialectical behaviour therapy programme.

Sexuality and gender minoritised (SGM) adolescents are at increased risk of self-injury and suicide, and experience barriers to accessing mental health support. Dialectical behaviour therapy (DBT) is an effective treatment for self-injury and emotion dysregulation in adolescent populations, but few studies have published outcomes of DBT for SGM young people. This study aimed to investigate treatment outcomes and completion for SGM adolescents and their cisgender and heterosexual peers, in the National & Specialist CAMHS, DBT service (UK). Treatment completion, and opting out before and during treatment were examined for sexual and gender identity groups, as well as changes by the end of treatment in emotion dysregulation, self-injury, in-patient bed-days, emergency department attendances, and borderline personality disorder, depression and anxiety symptoms. SGM adolescents were over-represented in this service, even after considering their increased risk for self-injury. No statistically significant differences were found for treatment completion between the sexual orientation and gender identity groups, although there were patterns indicating possible lower treatment uptake and completion that warrant further investigation. Clinical outcomes for treatment-completers showed improvement by the end of DBT for each group, with few exceptions. These results are from relatively small subsamples, and it was not possible to separate by sex assigned at birth. Findings should be treated tentatively and as early indications of effect sizes to inform future studies. This study suggests that DBT could be a useful treatment for SGM adolescents in a highly specialist treatment setting.

Effects of Benzodiazepine Exposure on Real-World Clinical Outcomes in Individuals at Clinical High Risk for Psychosis.

Animal models indicate GABAergic dysfunction in the development of psychosis, and that benzodiazepine (BDZ) exposure can prevent the emergence of psychosis-relevant phenotypes. However, whether BDZ exposure influences real-world clinical outcomes in individuals at clinical high risk for psychosis (CHR-P) is unknown. This observational cohort study used electronic health record data from CHR-P individuals to investigate whether BDZ exposure (including hypnotics, eg, zopiclone) reduces the risk of developing psychosis and adverse clinical outcomes. Cox proportional-hazards models were employed in both the whole-unmatched sample, and a propensity score matched (PSM) subsample. 567 CHR-P individuals (306 male, mean[±SD] age = 22.3[±4.9] years) were included after data cleaning. The BDZ-exposed (n = 105) and BDZ-unexposed (n = 462) groups differed on several demographic and clinical characteristics, including psychotic symptom severity. In the whole-unmatched sample, BDZ exposure was associated with increased risk of transition to psychosis (HR = 1.61; 95% CI: 1.03-2.52; P = .037), psychiatric hospital admission (HR = 1.93; 95% CI: 1.13-3.29; P = .017), home visit (HR = 1.64; 95% CI: 1.18-2.28; P = .004), and Accident and Emergency department attendance (HR = 1.88; 95% CI: 1.31-2.72; P < .001). However, after controlling for confounding-by-indication through PSM, BDZ exposure did not modulate the risk of any outcomes (all P > .05). In an analysis restricted to antipsychotic-naïve individuals, BDZ exposure reduced the risk of transition to psychosis numerically, although this was not statistically significant (HR = 0.59; 95% CI: 0.32-1.08; P = .089). BDZ exposure in CHR-P individuals was not associated with a reduction in the risk of psychosis transition or adverse clinical outcomes. Results in the whole-unmatched sample suggest BDZ prescription may be more likely in CHR-P individuals with higher symptom severity.

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation.

Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Mixed-methods realist evaluation. Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. This study is registered as PROSPERO CRD42017069741. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Impact of the COVID-19 pandemic, its related social restriction measures and vaccination campaign on emergency department attendances for epileptic seizures: An interrupted time-series analysis

AimTo investigate the impact of the outbreak of the COVID-19 pandemic, its related social restriction measure (national lockdown) and vaccination campaign on emergency department (ED) accesses for epileptic seizures. MethodsRetrospective observational analysis conducted on a consecutive cohort of patients who sought medical care at the ED of the General Hospital of Merano, Italy, from January 1, 2015, to December 31, 2021. We investigated the monthly ED attendances for epileptic seizures between the periods before and after the outbreak of the COVID-19 pandemic and the national lockdown (March 2020) using an interrupted time-series analysis with data standardized for 1000 accesses/month. As a further temporal cutoff, we used the start of the national vaccination campaign. ResultsBetween January 1, 2015, and December 31, 2021, a total of 415,005 ED attendances were recorded; 1,254 (0.3 %) were due to epileptic seizures. No significant difference was found in the rate of standardized ED accesses for epileptic seizures in March 2020 (time point of interest) to the pre-pandemic trend (0.33/1000; 95 %CI: −1.05 to 1.71; p = 0.637). Similarly, there was no difference between the pre- and post-pandemic trends (-0.02/1000; 95 %CI: −0.11 to 0.06; p = 0.600). When adopting January 2021 as time point of interest, we found no difference to the pre-vaccination trend (0.83/1000; 95 %CI: −0.48 to 2.15), and no difference in the pre- and post-vaccination trends (-0.12/1000; 95 %CI: −0.27 to 0.04). ConclusionsThe COVID-19 pandemic and its related social restrictions (lockdown), as well as the COVID-19 national vaccination campaign, had little impact on ED accesses for epileptic seizures.

Re-imagining crisis care: experiences of delivering and receiving the Assured brief psychological intervention for people presenting to Emergency Departments with self-harm.

Risk of suicide is increased immediately following emergency department (ED) attendance for self-harm. Evidence suggests that brief psychological interventions delivered in EDs are effective for self-harm. The Assured intervention comprises an enhanced biopsychosocial assessment in the ED, collaborative safety planning and three rapid solution focused follow-up sessions. We addressed the following research questions: What were ED mental health liaison practitioners' and patients' experiences of the Assured intervention? What were the barriers and facilitators? What might the mechanisms be for improving experiences and outcomes? We conducted a feasibility study of the Assured intervention in four EDs in Southeast England. Semi-structured interviews were conducted with 13 practitioners and 27 patients. Interviews were transcribed, coded line-by-line in Nvivo and thematically analysed using an inductive approach. Inter-rater reliability was calculated with a kappa coefficient of 0.744.

Improving the Diagnosis of Rib Fractures in the Emergency Department: A Quality Improvement Project in a District General Hospital in the United Kingdom.

Background Falls in older people are a common presentation in emergency departments (ED) in the United Kingdom. They can lead to multiple injuries, including chest wall injuries (CWIs). Untreated CWI carries significant morbidity and mortality. However, its diagnosis remains challenging during the initial ED encounter. This led to a quality improvement project (QIP) to improve the diagnosis of CWI in patients presenting to William Harvey Hospital, a district general, trauma-unit ED in Willesborough, England. Methods The QIP was run from February 2020 to April 2021 for 14 months. A series of plan-do-study-act (PDSA) cycles were completed to increase the proportion of CWIs diagnosed during the initial ED encounter to 90%. The primary interventions involved designing a new thoracic trauma proforma and the introduction of the modified pain, inspiratory effort, and cough (PIC) score to evaluate and triage patients with CWI. Other interventions included the delivery of an education programme on CWI. The secondary aims were to increase modified PIC score use and to reduce the time between ED presentation and computerised tomography (CT) scanning. Results A total of 147 patients were included in three PDSA cycles. The diagnosis of CWI during the initial ED encounter increased from 61% at baseline to 91%. The median time from ED attendance to the first CT reduced from 477 minutes to 169 minutes. Lastly, following the introduction of the thoracic trauma proforma, the modified PIC score was used in 26% of cases of CWI by the end of the QIP period. Conclusion Our QIP led to improvement in the early diagnosis of CWIs in ED, with significant improvements in door to CT time and the creation of a thoracic injury pathway in the trust leading to multi-specialty improvement of care of such patients.

Multisite development and validation of machine learning models to predict severe outcomes and guide decision-making for emergency department patients with influenza.

Millions of Americans are infected by influenza annually. A minority seek care in the emergency department (ED) and, of those, only a limited number experience severe disease or death. ED clinicians must distinguish those at risk for deterioration from those who can be safely discharged. We developed random forest machine learning (ML) models to estimate needs for critical care within 24h and inpatient care within 72h in ED patients with influenza. Predictor data were limited to those recorded prior to ED disposition decision: demographics, ED complaint, medical problems, vital signs, supplemental oxygen use, and laboratory results. Our study population was comprised of adults diagnosed with influenza at one of five EDs in our university health system between January 1, 2017 and May 18, 2022; visits were divided into two cohorts to facilitate model development and validation. Prediction performance was assessed by the area under the receiver operating characteristic curve (AUC) and the Brier score. Among8032 patientswith laboratory-confirmed influenza,incidence of critical care needs was 6.3% and incidence of inpatient care needswas 19.6%.Themost common reasons for ED visitwere symptoms of respiratory tract infection,fever,and shortness of breath. Model AUCswere0.89 (95% CI 0.86-0.93)for prediction of criticalcare and0.90(95% CI0.88-0.93)for inpatient care needs;Brier scores were0.026 and0.042, respectively.Importantpredictorsincludedshortness of breath,increasingrespiratory rate,and ahigh number of comorbid diseases. ML methods can be used to accurately predict clinical deterioration in ED patients with influenza and have potential to support ED disposition decision-making.