Emergency Department Attendances Research Articles

Quantifying the association between doula care and maternal and neonatal outcomes

BackgroundThe US suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and decrease this disparity. ObjectiveEvaluate the association of doula care with a broad range of maternal and neonatal outcomes in various subpopulations. Study DesignRetrospective cohort of deliveries from 1/2021-12/2022 at a single institution receiving prenatal care. Exposure was receipt of doula care prenatally and at delivery. We evaluated both maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean (VBAC), gestational hypertension, preeclampsia, postpartum emergency department visit, readmission and attendance at postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine fetal growth restriction) outcomes. Because our institution previously employed targeted outreach, offering doula services to patients at highest risk, we utilized multiple methods to generate an appropriate comparison population. We conducted multivariate logistic regression and conditional regressions using propensity scores, modeling likelihood of doula care, to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White/Black) then payor status (public/commercial). ResultsOur cohort included 17,831 deliveries; 486 with doula care and 17,345 without. Patients receiving doula care were more likely to self-report Black race, be publicly insured, and live in a more disadvantaged neighborhood. Regardless of analytic approach, for every 100 patients under doula care there were 15-34 more VBACs [adjRD 15.6 (95%CI: 3.8, 27.4); adjRD 34.2 (95%CI: 0.046, 68.0)] and 5-6 more patients attending a postpartum office visit [adjRD 5.4 (95%CI: 1.4, 9.5); adjRD 6.8 (95% CI:3.7, 9.9)] compared with those not receiving doula services.Infants born to these patients were 20% more like likely to be exclusively breastfed [adjRR 1.22 (95%CI: 1.07, 1.38)], and doula care was associated with 3-4 fewer preterm births [adjRD -3.8 (95%CI: -6.1, -1.5); -4.0 (95%CI: -6.2, -1.8)] for every 100 deliveries receiving doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula. ConclusionsDoula care was associated with more VBACs, attendance at postpartum office visit, breastfeeding, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

Using emergency department data to define a 'mental health presentation' - implications of different definitions on estimates of emergency department mental health workload.

Objective This study aimed to describe and compare the proportion of patients classified as an emergency department (ED) mental health presentation under different definitions, including the Australian Institute of Health and Welfare (AIHW) definition. Methods This retrospective cohort study enrolled all patients that presented to the EDs of a multi-centre Victorian health service between 1 January 2020 and 30 June 2023. Varying definitions of a mental health presentation were applied to each ED attendance, applying the current AIHW definition (using selected diagnosis codes), broader diagnosis-based coding, the presenting complaint recorded at triage and whether the patient was seen by or referred to the emergency psychiatric service (EPS). The proportion of all ED presentations meeting each definition and any overlap between definitions were calculated. The agreement between each definition and the AIHW definition was evaluated using Kappa's coefficient. Results There were 813,078 presentations to ED of which 34,248 (4.2%) met the AIHW definition for a mental health presentation. Throughout the study, 45,376 (5.6%) patients were seen and/or referred to EPS, and 36,160 (4.4%) patients were allocated a mental health presenting complaint by triage staff. There was moderate interrater agreement between these definitions, with a kappa statistic (95% confidence interval) between the AIHW definition and a mental health presenting complaint recorded at triage of 0.58 (0.58-0.59) and between the AIHW definition and review by EPS of 0.58 (0.57-0.58). Conclusions The AIHW definition is a conservative measure of ED mental health presentations and may underestimate emergency psychiatry workload in Australian EDs.

Machine Learning in Medical Triage: A Predictive Model for Emergency Department Disposition

The study explores the application of automated machine learning (AutoML) using the MIMIC-IV-ED database to enhance decision-making in emergency department (ED) triage. We developed a predictive model that utilizes triage data to forecast hospital admissions, aiming to support medical staff by providing an advanced decision-support system. The model, powered by H2O.ai’s AutoML platform, was trained on approximately 280,000 preprocessed records from the Beth Israel Deaconess Medical Center collected between 2011 and 2019. The selected Gradient Boosting Machine (GBM) model demonstrated an AUC ROC of 0.8256, indicating its efficacy in predicting patient dispositions. Key variables such as acuity and waiting hours were identified as significant predictors, emphasizing the model’s capability to integrate critical triage metrics into its predictions. However, challenges related to the complexity and heterogeneity of medical data, privacy concerns, and the need for model interpretability were addressed through the incorporation of Explainable AI (XAI) techniques. These techniques ensure the transparency of the predictive processes, fostering trust and facilitating ethical AI use in clinical settings. Future work will focus on external validation and expanding the model to include a broader array of variables from diverse healthcare environments, enhancing the model’s utility and applicability in global emergency care contexts.

Intravenous diltiazem infusions for rapid atrial fibrillation or flutter in the emergency department: A retrospective, exploratory analysis.

Emergency physicians commonly treat patients with atrial fibrillation (AF) or atrial flutter (AFL) with rapid ventricular response, and intravenous (IV) diltiazem is the most commonly used medication for rate control of such patients. We sought to compare rate control success and safety outcomes for emergency department (ED) patients with AF or AFL who, after a diltiazem bolus, received a diltiazem drip compared to those who did not receive a drip. We performed a retrospective cohort study comparing outcomes of ED patients from a single hospital system with AF and AFL and a heart rate (HR) > 100 beats/min who received a diltiazem drip after an IV diltiazem bolus to those who received no drip. The primary outcome was a HR < 100 beats/min at the time of ED disposition. Secondary outcomes were hospital length of stay and safety (hypotension, electrical cardioversion, vasopressor use, and death). We compared groups using propensity score matching. Between January 1, 2020, and November 8, 2022, there were 746 AF or AFL patients eligible for analysis. Of those, 382 (51.2%) received a diltiazem drip and 364 (48.8%) did not. In the unadjusted analysis, the last recorded ED HR was <100 beats/min in 55.2% of patients in the drip group compared to 65.9% in the no-drip group (difference 10.7%, 95% confidence interval [CI] 3.7 to 17.7). After propensity matching, diltiazem drip use was associated with lower likelihood of rate control in the ED (OR 0.69, 95% CI 0.48-0.99) and 22.5 h (95% CI 12.2-36.8) longer hospital stay. For patients with AF or AFL, the use of a diltiazem drip after an IV diltiazem bolus was associated with less rate control in the ED.

Integrating discrete-event simulation and artificial intelligence for shortening bed waiting times in hospitalization departments during respiratory disease seasons

Seasonal Respiratory Diseases (SRDs) usually produce a heightened number of Emergency Department (ED) attendances due to their rapid dissemination within the community and the ineffective prevention measures. Such a context requires effective management of the emergency care processes to provide in-time diagnosis and treatment to infected patients. Nonetheless, EDs have evidenced severe operational deficiencies during these periods, thereby provoking extended bed waiting times in Hospitalization Departments (HDs). Therefore, this paper presents a hybrid approach merging Artificial Intelligence (AI) and Discrete-Event Simulation (DES) to shorten the bed waiting times in HDs considering patient records collated in the first emergency care stages. First, we implemented Random Forest (RF) to estimate the probability of respiratory worsening based on sociodemographic and clinical patient data. Second, we inserted these probabilities into a DES model mimicking the emergency care from the admission to the HD. We then pretested different HD configurations and strategies seeking to reduce the HD bed waiting time. A case study of a European hospital group was used to validate the suggested framework. The AI-DES model enabled decision-makers to identify an improvement proposal with hospitalization bed waiting time lessening, oscillating between 7.93 and 7.98 h.

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...

Peadiatric Trauma Score - A Quick Mass Casualty Scenario Assessment Tool?

AIMS : The objective of this study was to evaluate the association of the Pediatric Trauma Score (PTS) polytrauma in relation to emergency department (ED) disposition in pediatric trauma patients. Materials and Methods: PTS was deduced from data drawn from a mass casualty scenario that arrived at the ER of MGM Hospital which comprised of triaged- 5 red cases, 15 yellow cases and 19 green cases

The Impact of a High Sensitivity Troponin HEART Pathway Based Clinical Decision Protocol on Observation Visits.

Use of high-sensitivity troponin (hs-cTn) might lead to an increase in hospital observation visits due to higher number of abnormal troponin levels. To determine the impact of incorporating hs-cTn into a chest pain clinical decision protocol (CDP) on observation visits in a large academic health system. This is a retrospective observational cohort study of all chest pain observation patients in four hospitals in an academic health system over 24 months. All hospitals used the Beckman Coulter Unicel Dxi instrument, and all shared the same emergency department (ED) chest pain protocol, which used the HEART pathway and serial troponins and directed ED dispositions to either an observation stay, ED discharge, or inpatient admission. Outcomes studied before and after introduction of a hs-cTn protocol included daily chest pain observation census, cost, observation hours, and inpatient admit rate. Census was reported as the daily chest pain observation census and as a proportion of all observation visits. Data was retrieved from a health system data warehouse and a cost accounting program. There were 6,712 chest pain observation visits over 24-months, with 4,087 visits before and 2,634 visits after the hs-cTn protocol implementation. Comparison groups were similar in terms of age, gender, and type of insurance. There were 10.59 (95% CI: 10.24 - 10.95) daily chest pain observation visits before and 7.66 (95% CI: 7.34 - 7.97) visits after implementation, with a 28% (95% CI: 35% - 20%) decrease in the total daily census. As a portion of all observation visits, there was a 22% drop in the proportion that were observed for chest pain. The daily number of chest pain patients requiring inpatient admission was unchanged. The daily total direct cost for chest pain observation decreased with an effective daily cost savings of $4,313 USD (95% CI: $1,534 - $6,998). The total daily number of chest pain observation bed hours also decreased by 41.5 hours (95% CI 13.4 - 96.4 hr). Implementation of a hs-cTn chest pain protocol was associated with a significant decrease in the number and proportion of observation visits, a decrease in total daily cost and bed hours used, and no increase in inpatient admissions.

Ethnicity and outcomes for patients with gastrointestinal disorders attending an emergency department serving a multi-ethnic population

BackgroundEthnic inequalities in acute health acute care are not well researched. We examined how attendee ethnicity influenced outcomes of emergency care in unselected patients presenting with a gastrointestinal (GI) disorder.MethodsA descriptive, retrospective cohort analysis of anonymised patient level data for University Hospitals of Leicester emergency department attendees, from 1 January 2018 to 31 December 2021, receiving a diagnosis of a GI disorder was performed. The primary exposure of interest was self-reported ethnicity, and the two outcomes studied were admission to hospital and whether patients underwent clinical investigations. Confounding variables including sex and age, deprivation index and illness acuity were adjusted for in the analysis. Chi-squared and Kruskal–Wallis tests were used to examine ethnic differences across outcome measures and covariates. Multivariable logistic regression was used to examine associations between ethnicity and outcome measures.ResultsOf 34,337 individuals, median age 43 years, identified as attending the ED with a GI disorder, 68.6% were White. Minority ethnic patients were significantly younger than White patients. Multiple emergency department attendance rates were similar for all ethnicities (overall 18.3%). White patients had the highest median number of investigations (6, IQR 3–7), whereas those from mixed ethnic groups had the lowest (2, IQR 0–6). After adjustment for age, sex, year of attendance, index of multiple deprivation and illness acuity, all ethnic minority groups remained significantly less likely to be investigated for their presenting illness compared to White patients (Asian: aOR 0.80, 95% CI 0.74–0.87; Black: 0.67, 95% CI 0.58–0.79; mixed: 0.71, 95% CI 0.59–0.86; other: 0.79, 95% CI 0.67–0.93; p < 0.0001 for all). Similarly, after adjustment, minority ethnic attendees were also significantly less likely to be admitted to hospital (Asian: aOR 0.63, 95% CI 0.60–0.67; Black: 0.60, 95% CI 0.54–0.68; mixed: 0.60, 95% CI 0.51–0.71; other: 0.61, 95% CI 0.54–0.69; p < 0.0001 for all).ConclusionsSignificant differences in usage patterns and disparities in acute care outcomes for patients of different ethnicities with GI disorders were observed in this study. These differences persisted after adjustment both for confounders and for measures of deprivation and illness acuity and indicate that minority ethnic individuals are less likely to be investigated or admitted to hospital than White patients.

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 analysis of NHS 111 demand for primary care services: A retrospective cohort study.

The NHS 111 service triages over 16,650,745 calls per year and approximately 48% of callers are triaged to a primary care disposition, such as a telephone appointment with a general practitioner (GP). However, there has been little assessment of the ability of primary care services to meet this demand. If a timely service cannot be provided to patients, it could result in patients calling 999 or attending emergency departments (ED) instead. This study aimed to explore the patient journey for callers who were triaged to a primary care disposition, and the ability of primary care services to meet this demand. We obtained routine, retrospective data from the Connected Yorkshire research database, and identified all 111 calls between the 1st January 2021 and 31st December 2021 for callers registered with a GP in the Bradford or Airedale region of West Yorkshire, who were triaged to a primary care disposition. Subsequent healthcare system access (111, 999, primary and secondary care) in the 72 hours following the index 111 call was identified, and a descriptive analysis of the healthcare trajectory of patients was undertaken. There were 56,102 index 111 calls, and a primary care service was the first interaction in 26,690/56,102 (47.6%) of cases, with 15,470/26,690 (58%) commenced within the specified triage time frame. Calls to 999 were higher in the cohort who had no prior contact with primary care (58% vs 42%) as were ED attendances (58.2% vs 41.8), although the proportion of avoidable ED attendances was similar (10.5% vs 11.8%). Less than half of 111 callers triaged to a primary care disposition make contact with a primary care service, and even when they do, call triage time frames are frequently not met, suggesting that current primary care provision cannot meet the demand from 111.

1167 A Closed Loop Audit to Benchmark Care for Emergency Department Attendances with Renal Colic

1167 A Closed Loop Audit to Benchmark Care for Emergency Department Attendances with Renal Colic

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.

Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

The cost effectiveness of early assessment and intervention by a dedicated health and social care professional team for older adults in the emergency department compared to treatment-as-usual: Economic evaluation of the OPTI-MEND trial.

Over 65s are frequent attenders to the Emergency Department (ED) and more than half are admitted for overnight stays. Early assessment and intervention by a dedicated ED-based Health and Social Care Professionals (HSCP) team reduces ED length of stay and the risk of hospital admissions among older adults while improving patient health-related quality-of-life and satisfaction with care. This study aims to evaluate whether augmenting the treatment as usual for older adults admitted to ED is cost-effective. Cost-effectiveness analysis (CEA), conducted alongside the OPTI-MEND randomised controlled trial of 353 patients aged ≥65 with lower urgency complaints compared the effectiveness of early assessment and intervention by a dedicated HSCP team in the ED to treatment as usual (TAU). An economic analysis estimated the average cost per older adults randomised to the HSCP team, and compared to TAU, how contact with HSCP team changed health care use, and associated total costs, and estimated the effect of HSCP on Quality-Adjusted Life Years (QALYs). Within the OPTI-MEND trial, the average cost of a contact with the HSCP team during ED attendance is estimated to be €801 per patient. Compared to TAU, the incremental QALY of intervention is 0.053 (95% CI: 0.023 to 0.0826, p<0.0001). Accounting for cost savings because of contact with HSCP team, the average incremental saving in the total cost, compared to TAU, is -€6,128 (95% CI: -€9,217 to -€3,038, p<0.0001). Given the incremental health gains and significant cost savings, bootstrapped cost CEA suggests that dedicated HSCP care dominates over TAU for low urgency older adults attending the ED. A dedicated HSCP team in the ED significantly improves overall health for lower acuity older adults and, by reducing inpatient length of stay, results in staggering cost savings. This economic evaluation conducted on the OPTI-MEND trial provides convincing evidence that HSCP should be adopted as part of treatment as usual in Irish EDs. ClinicalTrials.gov, NCT03739515; registered on 12th November 2018. https://classic.clinicaltrials.gov/ct2/show/NCT03739515.

Missed Opportunities: A Retrospective Study of Hepatitis C Testing in Hospital Inpatients.

Increasing testing is key to achieving hepatitis C elimination. This retrospective study aimed to assess the testing cascade of patients at a regional hospital in Victoria, Australia, who inject drugs or are living with hepatitis C, to identify missed opportunities for hepatitis C care. Adult hospital inpatients and emergency department (ED) attendees from 2018 to 2021 with indications for intravenous drug use (IDU) or hepatitis C on their discharge or ED summary were included. Data sources: hospital admissions, pathology, hospital pharmacy, and outpatients. We assessed progression through the testing cascade and performed logistic regression analysis for predictors of hepatitis C care, including testing and treatment. Of 79,923 adults admitted, 1345 (1.7%) had IDU-coded separations and 628 (0.8%) had hepatitis C-coded separations (N = 1892). Hepatitis C virus (HCV) status at the end of the study was unknown for 1569 (82.9%). ED admissions were associated with increased odds of not providing hepatitis C care (odds ratio 3.29, 95% confidence interval 2.42-4.48). More than 2% of inpatients at our hospital have an indication for testing, however, most are not being tested despite their hospital contact. As we work toward HCV elimination in our region, we need to incorporate testing and linkage strategies within hospital departments with a higher prevalence of people at risk of infection.

'I've got to go in there with my armour on': Adverse Childhood Experiences Among Adults Who Frequently Attend Emergency Departments.

Frequent presentations to emergency departments contribute to increased service demands and healthcare costs. Literature suggests these adult presentations may be influenced by childhood adversity. This qualitatively driven, mixed methods study explored the self-perceived role of childhood adversity in the health of adults who frequently attended Australian Emergency Departments and their perceptions of the healthcare they received. Data were collected using validated instruments and semi-structured interviews with 12 purposefully sampled adults who frequently attended emergency departments. Qualitative data were analysed using interpretive phenomenological analysis. Three major themes were identified-The experience of childhood adversity: articulating challenges related to childhood trauma, and the subsequent impacts on participants' health, behaviours, relationships and sense of control; Pursuing safety: exploring action participants took to keep themselves and others safe, with this requirement extending into adulthood and influencing Emergency Department presentations; and Seeking humanising healthcare: identifying challenges participants experienced while seeking care in the Emergency Department. Participants perceived their mental health to be profoundly affected by their past experiences of trauma, leaving them feeling vulnerable at times and more likely to experience re-traumatisation in the Emergency Department. Feelings of stigmatisation during Emergency Department encounters led participants to employ self-protection strategies creating further barriers to recovery. Participants described Emergency Departments as often failing to comprehensively address their healthcare needs. They offered suggestions for more effective care interventions. Findings highlight the need for further research to inform policy and practice when designing and implementing interventions for these adults. Consolidated Criteria for Reporting Qualitative Research (COREQ) guided study reporting.

Patterns of Mental Health Service Utilisation: A Population-Based Linkage of Over 17 Years of Health Administrative Records.

A cross-sectoral partnership was formed in 2021 in support of the recommendations in an audit on access to state-funded mental health services. In this first paper, we aimed to describe the demographic and service utilisation of adults with a mental health diagnosis in the Western Australian state-funded health system from 2005 to 2021. Inpatient, emergency department, specialised (ambulatory) community mental health service, and death records were linked in individuals aged ≥ 18 years with a mental health diagnosis in Western Australia. Altogether, 392,238 individuals with at least one mental health service contact between 1st January 2005 and 31st December 2021 were included for analysis. Females, Aboriginal and/or Torres Strait Islander people, and those who lived outside major cities or in the most disadvantaged areas were more likely to access state-funded mental health services. While the number of individuals who accessed community mental health services increased over time (from 28,769 in 2005 to 50,690 in 2021), the percentage increase relative to 2005 was notably greater for emergency department attendances (127% for emergency department; 76% for community; and 63% for inpatient). Conditions that contributed to the increase for emergency department were mainly alcohol disorder, reaction to severe stress and adjustment disorders, and anxiety disorders. Sex differences were observed between conditions. The pattern of access increased for emergency department and the community plus emergency department combination. This study confirmed that the patterns of access of state-funded mental health services have changed markedly over time and the potential drivers underlying these changes warrant further investigation.

Clinical effectiveness and safety of adding a self-harm prevention app (BlueIce) to specialist mental health care for adolescents who repeatedly self-harm: A single blind randomised controlled trial (the BASH study)

No randomised controlled trials have evaluated whether the addition of a smartphone app to usual child and adolescent mental health care (CAMHS) can reduce self-harm in adolescents (<18 years) with repeated self-harm. We enrolled 170 participants aged 12–17, receiving CAMHS treatment who had self-harmed ≥2 in the past 12 months. Participants were randomised via an independent web-based system (1:1, minimised for gender, age, self-harm frequency, and depression severity) to treatment as usual (TAU) or treatment as usual plus BlueIce (TAU+BI). BlueIce is a self-harm prevention app that includes techniques from CBT and DBT that was co-designed with adolescents who self-harm. The primary outcome was change from baseline to 12-weeks on the self-harm scale of the Risk Taking and Self-Harm Inventory for Adolescents (RTSHIA), analysed by intention to treat (ITT). Emergency department attendances or admissions for self-harm were assessed over 6-months via a review of clinical records. Both groups improved but there were no statistically significant between group differences at 12 weeks or 6 months on the self-harm scale of the RTSHIA. There were fewer emergency department attendances and admissions in those who received the app, a finding that approached statistical significance. BlueIce can be helpful in some important aspects by contributing to fewer emergency department admissions and attendances. Trial registrationTrial registration number ISRCTN10541045.

An Evaluation of the Demographics, Characteristics and Healthcare Utilisation of People with Asthma Referred to an Ambulatory Respiratory Hub

Background Asthma is the most treated condition in the Ulster Hospital Ambulatory Respiratory Hub (ARH). This multidisciplinary rapid assessment and treatment centre reviews respiratory patients to prevent hospital admission. This service evaluation (SE) may identify improvements for the service and better outcomes for asthma patients. Aims The demographics, clinical characteristics including biomarker profile and co-morbidities, alongside subsequent healthcare utilisation of patients with asthma were explored. Method Retrospective review of electronic healthcare records identified 151 patients with asthma attending the ARH between 1st July 2019 and 31st Dec 2019. Baseline demographics, clinical characteristics, comorbidities and asthma biomarkers were extracted. Patients were characterised according to their T2-biomarker expression and comparisons made. Healthcare utilisation was assessed by collecting data regarding hospital admissions, emergency department attendances and GP out of hours visits 6 months before and after attending the service. Results Most patients with asthma were female (73.5%), T2- biomarker low (74.2%) and had a high prevalence of obesity (49%). Prevalent comorbidities included rhinosinusitis, gastro-oesophageal reflux disease, depression and anxiety. Investigations included spirometry, chest x-ray and asthma biomarkers (fraction of exhaled nitric oxide and blood eosinophil count). Hospital admissions were reduced by 93%, ED attendances by 83.4% and GP OOH visits by 71.4% during the 6-month period following attendance. Conclusions The identification and management of common asthma comorbidities is important and should be routinely assessed. The ARH reduces healthcare utilisation for patients attending with asthma. It could provide additional support to the regional service enabling quicker access to biologic therapies.

Individualized throughput metric reports for emergency medicine residents: Impact on time to disposition and resident perceptions.

Research suggests that quantitative metric reports can improve the clinical performance of emergency physicians; however, few studies have examined their effects on physicians in training. The primary study objective was to assess the effects of providing emergency medicine (EM) residents with individualized throughput metrics with regard to emergency department (ED) disposition times. We performed a single-center, retrospective, observational study from January 2021 to December 2022 examining ED disposition times before and after providing upper-level EM residents individualized throughput metrics. Residents received monthly reports of three specific metrics averaged over the preceding 6 months: (1) median time from room to discharge order (Rm2Dc), (2) median time from return of all results to discharge order (Rlts2Dc), and (3) median time from room and to consult order for hospitalization (Rm2Hosp). Overall mean values of the three metrics before and during metric sharing were compared via independent t-test and stratified by level of training and time of year. Adjusted analysis was performed to control for temporal differences between study periods. Testing was conducted at α = 0.05 level of significance. A total of 35 unique residents were included in the analysis. Overall, mean disposition times were not significantly different before and during reporting of metrics: Rm2Dc (154.8 min vs. 148.9 min, p = 0.109), Rslt2Dc (46.5 min vs. 45.1 min, p = 0.522), and Rm2Hosp (141.7 min vs. 135.7 min, p = 0.257). Subgroup analysis yielded similar results, aside from a significant decrease in mean Rm2Hosp in the postgraduate year-3 (PGY-3) group (145.8 min vs. 124.1 min, p = 0.004). Analysis with adjusted means yielded results similar to those observed with unadjusted data. Overall, individualized throughput metrics were not correlated with decreased average times to ED disposition for upper-level EM residents; however, in the subset of hospitalized patients seen by PGY-3 residents, we observed a mean decrease of 21.7 min to consultation.