Emergency Department Documentation Research Articles

Use of a Large Language Model to Assess Clinical Acuity of Adults in the Emergency Department

The introduction of large language models (LLMs), such as Generative Pre-trained Transformer 4 (GPT-4; OpenAI), has generated significant interest in health care, yet studies evaluating their performance in a clinical setting are lacking. Determination of clinical acuity, a measure of a patient's illness severity and level of required medical attention, is one of the foundational elements of medical reasoning in emergency medicine. To determine whether an LLM can accurately assess clinical acuity in the emergency department (ED). This cross-sectional study identified all adult ED visits from January 1, 2012, to January 17, 2023, at the University of California, San Francisco, with a documented Emergency Severity Index (ESI) acuity level (immediate, emergent, urgent, less urgent, or nonurgent) and with a corresponding ED physician note. A sample of 10 000 pairs of ED visits with nonequivalent ESI scores, balanced for each of the 10 possible pairs of 5 ESI scores, was selected at random. The potential of the LLM to classify acuity levels of patients in the ED based on the ESI across 10 000 patient pairs. Using deidentified clinical text, the LLM was queried to identify the patient with a higher-acuity presentation within each pair based on the patients' clinical history. An earlier LLM was queried to allow comparison with this model. Accuracy score was calculated to evaluate the performance of both LLMs across the 10 000-pair sample. A 500-pair subsample was manually classified by a physician reviewer to compare performance between the LLMs and human classification. From a total of 251 401 adult ED visits, a balanced sample of 10 000 patient pairs was created wherein each pair comprised patients with disparate ESI acuity scores. Across this sample, the LLM correctly inferred the patient with higher acuity for 8940 of 10 000 pairs (accuracy, 0.89 [95% CI, 0.89-0.90]). Performance of the comparator LLM (accuracy, 0.84 [95% CI, 0.83-0.84]) was below that of its successor. Among the 500-pair subsample that was also manually classified, LLM performance (accuracy, 0.88 [95% CI, 0.86-0.91]) was comparable with that of the physician reviewer (accuracy, 0.86 [95% CI, 0.83-0.89]). In this cross-sectional study of 10 000 pairs of ED visits, the LLM accurately identified the patient with higher acuity when given pairs of presenting histories extracted from patients' first ED documentation. These findings suggest that the integration of an LLM into ED workflows could enhance triage processes while maintaining triage quality and warrants further investigation.

610 From Flames to Facts: Unveiling Discrepancies in Burn Patient Documentation

Abstract Introduction Comprehensive and accurate burn documentation is essential for initial and ongoing patient care. However, the challenge of inaccurate and incomplete records poses preventable risks. Our study evaluates burn documentation at a tertiary care burn centre, focusing on discrepancies between initial Emergency Department (ED) assessments and final evaluations by the Plastic Surgery Burn Consultant (PS). We hypothesize that the ED reports inaccurate and incomplete burn injury details, leading to differences in burn size and severity compared to PS assessments. Methods We conducted a retrospective review of our provincial burn registry from January 1, 2016, to December 31, 2021. We included patients admitted for burns warranting a PS consultation, excluding isolated first-degree, ocular, and inhalational burns, and those not requiring burn unit admission. Data covering time, date, etiology, injury details, treatment, and follow-up were collected and compared between ED and PS records. Incomplete entries lacked burn-specific data points. Mann-Whitney and Kruskal-Wallis H tests were used to compare continuous outcomes, while Pearson’s Chi-Square test was employed for categorical outcomes. Wilcoxon’s Signed-Rank test was used to identify significant variations in TBSA estimates, with PS considered the "gold" standard. Statistical significance was set at p< 0.05. Results 358 patients were included, with most burns in male patients (76%) occurring at home and involving the head and neck. Burn etiology, circumstances, place, and anatomic location were well reported and consistent across PS and ED documentation. However, there were significant differences in TBSA estimates. The ED calculated a median TBSA of 20 (IQR: 19.8), while PS estimated a median TBSA of 14 (IQR: 16) (p< 0.0019). Notably, TBSA estimates for burns < 10% and 10-25% showed significant differences (p< 0.0001), tending toward overestimation by the ED. Deeper burns were consistently over-reported during initial ED assessments compared to the final PS determinations. Furthermore, 81% of the initial records were incomplete: 66% lacked initial treatment data, 49% missed TBSA, and 39% omitted burn depth. Conclusions Significant discrepancies were appreciated in the initial ED documentation of burn injuries at our tertiary care burn centre, with overestimations in TBSA and burn depth. Over 80% of initial documentation was incomplete, with TBSA omitted in 49% of charts in both local and peripheral transfer consultations. There is a collective urgent need for enhanced awareness and education on the importance of accurate and comprehensive burn patient documentation. Applicability of Research to Practice This research emphasizes the need for improved documentation strategies for burn patients seen in the acute care setting, raising the potential to venture into modalities such as artificial intelligence and electronic health record systems to enhance burn documentation.

Improving Mental Health Communication From the Pediatric Emergency Department to Primary Care.

Suicide is a leading cause of adolescent death, and emergency department (ED) visits are recognized as an opportunity to identify at-risk youth. For patients screening positive for mental health concerns, we implemented a quality improvement initiative to enhance documentation of results and interventions in the ED, increase communication between the ED and primary care providers (PCPs), and increase PCP follow-up. Interventions included education, feedback, and an alert in our electronic health record. Completion of a Behavioral Health Screen (BHS-ED) initiates an alert that reminds ED providers how to document and communicate results and needed follow-up to the PCP. We reviewed a random monthly sample of ED charts for adolescents 14 to 19 years old presenting with nonpsychiatric complaints who screened positive for severe depression or suicidality. Outcome measures included documentation of BHS-ED results in the ED note, communication of positive results to the PCP, PCP follow-up of results, and ED return visits. Documentation of BHS-ED results increased from 73% at baseline to 88% of patients after the intervention. For patients discharged from the ED with nonpsychiatric chief complaints, communication to PCPs increased from 1% at baseline to 40% during the final 3 months of the study. When PCP communication occurred, 67% of in-network PCPs followed up with patients versus 5% when no communication took place from the ED. A multifaceted intervention including education and an electronic health record alert improved ED documentation, communication, and PCP follow-up of issues identified during ED-based mental health screens.

MP09: Predictors of return acute asthma visits among patients receiving guideline recommended discharge management in the emergency department

Introduction: Despite improvements in the recognition of asthma among the pediatric population and the use of preventative therapies, rates of emergency department (ED) visits and hospitalizations remain high, leading one to question how these acute health care visits for asthma can be further avoided. In this study, we aimed to identify predictors of future repeat acute care visits among children and adolescents who had already received ‘best practice’ discharge treatments and instructions during their first asthma ED visit. Methods: We performed a retrospective single center cohort study of all children ages 1-17 years presenting to the ED at the Children's Hospital of Eastern Ontario in Ottawa, Canada for an acute asthma exacerbation during a 1-year time frame between September 1, 2014 – August 31, 2015. Only children with no prior ED asthma visit and documentation of receipt of a prescription for inhaled corticosteroids and/or a written asthma action plan were included. Multivariable logistic regression was performed to identify predictors of repeat future asthma ED visit or hospitalization in the year following the first ED visit. Results: We identified 909 children with an eligible ED visit during the study period, of whom 24% had a repeat asthma ED visit or hospitalization within the subsequent 1 year. Predictors of repeat acute asthma visits included having a nut allergy (OR 1.76, 95% CI: 1.15, 2.70), higher severity symptoms at triage (OR 2.04, 95% CI: 1.23, 3.39), a primary care physician (OR 2.23, 95% CI: 1.26, 3.93), or a prior history of asthma (OR 1.53, 95% CI: 1.03, 2.28). Conclusion: In children and adolescents with repeat asthma ED visits and hospitalizations despite having received ‘best practice’ asthma discharge management at their first ED visit, factors such as having an allergy to nuts, higher severity symptoms at presentation, a prior history of asthma, and having a primary care provider may be used to identify these more high-risk children and adolescents. Such parameters can be used practically to target and apply more intensive preventative interventions to those most in need at the first ED visit, in order to prevent future return visits.

Prevalence and practice of opioid prescription at a Swiss emergency department: 2013-2017.

Addiction associated with prescription opioids is increasing worldwide, including Switzerland. We aimed (1) to determine whether the prevalence and incidence of opioid therapy at an emergency department (ED) in Switzerland has changed over five years and (2) to characterise consultations with incident opioid prescription. In this retrospective chart review, pre-existing opioid treatment and new prescriptions at the ED of Bern University Hospital “Inselspital”, Switzerland, between 2013 and 2017 were identified from the ED documentation system. Patients already taking opioids before presentation (prevalent opioid use) were distinguished from opioid-naïve patients who were prescribed opioids for the first time (incident opioid prescription) and relative numbers in every half year from 2013 to 2017 were calculated. Demographic and consultation characteristics were analysed to determine factors associated with incident opioid prescription. Within the observation period, 199,299 patients consulted the ED. Of those, 4.95% (95% confidence interval [CI] 4.86–5.05, n = 9868) were using opioids on admission. Nearly 7.07% of them (95% CI 6.57–7.58, n = 698), 0.35% of the complete sample, were prescribed additional opioids. Incident opioid prescription for opioid-naïve patients was found in 2.26% of patients (95% 2.19–2.32, n = 4499). The relative number of prevalent opioid users did not show a significant (p = 0.163) association with time (categorised in half years) when adjusted for the potential confounders age group, trauma, the interaction of trauma and age group, other chief complaint, type of admission and time of admission. Incident opioid prescriptions significantly decreased over the study period (slope = −0.041% per half year, standard error = 0.012%, p = 0.007). The trend persisted after adjustment for the abovementioned potential confounders. Consultations resulting in opioid prescription were significantly associated with older age, musculoskeletal disorders and trauma (p <0.05). Opioid prescriptions in a Swiss ED decreased between 2013 and 2017. Although this might be a sign of awareness of the risks of opioid prescription, the conclusion is derived from a single centre study and the observed trend warrants confirmation by data from other sources.

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway.

ObjectiveBedside consultation by cardiologists may facilitate safe discharge of selected patients from the emergency department (ED) even when admission is recommended by the History, Electrocardiogram, Age, Risk factors, Troponin (HEART) pathway. If bedside evaluation is unavailable, phone consultation between emergency physicians and cardiologists would be most impactful if the resultant disposition is discordant with the HEART pathway. We therefore evaluate discordance between actual disposition and that suggested by the HEART pathway in patients presenting to the ED with chest pain for whom cardiology consultation occurred exclusively by phone and to assess the impact of phone-consultation on disposition.MethodsWe performed a single-center, retrospective study of adults presenting to the ED with chest pain whose emergency physician had a phone consultation with a cardiologist. Actual disposition was abstracted from the medical record. HEART pathway category (low-risk, discharge; high-risk, admit) was derived from ED documentation. For discharged patients, major adverse cardiac events were assessed at 30 days by chart review and phone follow-up.ResultsFor the 170 patients that had cardiologist phone consultation, discordance between actual disposition and the HEART pathway was 17%. The HEART pathway recommended admission for nearly 80% of discharged patients. Following cardiologist phone-consultation, 10% of high-risk patients were discharged, with the majority having undergone a functional study recommended by the cardiologist. At 30 days, discharged patients had experienced no episodes of major adverse cardiac events or rehospitalization for cardiac reasons.ConclusionFor patients presenting to the ED with chest pain, cardiology phone-consultation has the potential to safely impact disposition, primarily by facilitating functional testing in high-risk individuals.

Teen Dating Violence: Old Disease in a New World

Teen dating violence (TDV) is an underrecognized and significant public health problem that affects millions of adolescents each year. Many teens seek care in the emergency department (ED) for their injuries due to TDV, and are at risk for negative short- and long-term outcomes. With a better understanding by ED clinicians of normal adolescent development, as well as the impact of TDV on the health and safety of teen patients, the ED setting can serve as an effective site for both intervention and violence prevention. This article provides an overview of the importance of this issue, the impact of technology and social media on TDV, and best practices for ED screening, documentation, and referral.

High Diagnostic Uncertainty and Inaccuracy in Adult Emergency Department Patients With Dyspnea: A National Database Analysis.

High Diagnostic Uncertainty and Inaccuracy in Adult Emergency Department Patients With Dyspnea: A National Database Analysis.

128 The Quick Sequential Organ Failure Assessment Identifies Septic Patients in the Out-of-Hospital Setting

The primary objective is to determine whether a out-of-hospital quick Sequential Organ Failure Assessment (qSOFA) screening obtained by emergency medical services (EMS) providers correlates with emergency department (ED) sepsis diagnosis. Secondary objectives were to evaluate characteristics of the out-of-hospital qSOFA cohort as related to sepsis. This included EMS call information, patient demographics (age and sex), measured systemic inflammatory response syndrome (SIRS) criteria, lactate, placement of central venous access, and ED mortality. A qSOFA screen is positive when the respiratory rate is greater than 22, systolic blood pressure (SBP) is less than 90 mmHg, and there is an altered mental status (AMS). A retrospective hospital-based 911 EMS chart review was conducted for patients received at the hospital campus sites. The study period was 1/1/2014 to 6/30/2014. Out-of-hospital charts were filtered for the 2 vital sign criteria for qSOFA and matched with their respective ED charts by identifiers. The EMS charts were reviewed for out-of-hospital documentation of AMS by any of the following criteria: Glasgow Coma Scale under 15, AVPU score of V P or U, Chief Complaint of AMS, AMS documented by provider, Individual EMS chart review. EMS charts were excluded for patients less than 18 years, inqSOFA documentation, or patients in cardiac arrest who did not achieve return of spontaneous circulation. Additionally, duplicate or non-911 charts were removed. Researchers blinded to ED outcome performed EMS chart review. ED charts were reviewed to clarify which out-of-hospital qSOFA patients were septic vs. non-septic. ED septic patients were defined as an admit diagnosis of: sepsis, severe sepsis, septic shock or if the patient met more than 2 SIRS criteria and a documented infection. Researchers blinded to EMS chart performed ED outcome review. Within the study period, 271 EMS charts met the filter criteria for 2-value qSOFA. Of these, 28 were excluded as inter-facility transfer calls, leaving 243 true 911 responses remaining. AMS was not documented in 162 of the 243 leaving 81 remaining as screening positive for 3-value out-of-hospital qSOFA. Nine of 81 charts were removed due to insufficient ED documentation, leaving 72 for analysis. Forty-eight of the 72 patients were identified as ED Septic and 24 ED Non-Septic. The positive predictive value of the out-of-hospital qSOFA in our study was 66.67% (95% CI 55.8-77.6%). The ED septic cohort had a higher average number of SIRS criteria vs. non-septic: 2.67 vs. 1.41 respectively. Lactate values were equivalent at 4.10 vs. 4.06. Of the 53 patients that met > 2 SIRS criteria in the ED, 81.1% were Septic. Mortality was low overall, but higher in the ED septic (3/45, 7%) vs. non-septic (1/23, 4%). Central access was higher in ED septic (17/31, 55%) vs. non-septic (5/19, 26%). The qSOFA is a useful screening tool that requires no formal testing or equipment and can be used to identify patients who require prompt intervention and resuscitation. Sepsis remains a diagnostic difficulty for EMS providers due to absence of obvious findings. Vital signs and mental status are ubiquitously recorded by EMS. Close attention to derangements of these assist in the identification of critically ill patients. A positive qSOFA should prompt rapid ED evaluation. Additionally, the qSOFA likely has high inter-rater reliability, requires no special devices or equipment and can be repeated as needed during a call.

IMPACT OF POINT OF CARE CRP TESTING ON THE MANAGEMENT OF PATIENTS WITH SUSPECTED COMMUNITY ACQUIRED PNEUMONIA IN THE ED

Objectives & BackgroundThe World Health Organisation has identified antimicrobial resistance as “an increasingly serious threat to global public health that requires action across all government sectors and society”, and state...

A multi-hospital analysis of predictors of oral anticoagulation prescriptions for patients with actionable atrial fibrillation who attend the emergency department.

Atrial fibrillation (AF) is the most common arrhythmia and is associated with an increase in the risk of ischemic stroke. The risk of stroke can be significantly decreased by oral anticoagulation (OAC). Our objective was to characterize the filling of OAC prescriptions for patients with actionable AF (new or existing AF with an indication for OAC but not prescribed) and determine the prevalence and predictors of guideline-appropriate therapy at 30days. This is a multi-hospital, retrospective cohort study of patients who visited the Emergency Department (ED) and had a discharge diagnosis of AF. Patient records were examined to identify demographics, risk factors, and prescription data. Predictors of filling a prescription at 30days were analyzed. 788 patients with AF were reviewed. 257 patients had actionable AF. Forty one percent (104) had newly diagnosed AF. The mean CHADS2 score was 2±1. At 30days after discharge, 25.7% of patients filled a prescription for OAC therapy. Large numbers of patients attending the ED have actionable AF, but rates of guideline-directed OAC at thirty days are low. Only a prescription written by the ED physician (OR 9.89) and documentation of stroke risk stratification in the patients' chart (OR 4.09) were associated with the primary outcome.

The Utility of Inflammatory and Endothelial Markers to Identify Infection in Emergency Department Patients.

Background Identifying infection in emergency department (ED) patients can be challenging. This study assesses the value that inflammatory and endothelial biomarkers add to clinical data when predicting infectious etiologies of abnormal vital signs (AVSs) in ED patients. Methods This study was a prospective, observational cohort study of ED patients with AVSs at an urban, academic tertiary-care hospital, identified from March 1, 2013, to April 15, 2013. Collected blood samples were assayed for soluble E-selectin (sE-selectin), soluble intercellular adhesion molecule 1, vascular cell adhesion molecule 1, plasminogen activator inhibitor 1, interleukin 6, sFlt-1, and procalcitonin. History and physical examination were abstracted from the ED documentation. The primary outcome, infectious etiology, was adjudicated by review of the hospital documentation. Three multivariate logistic regression models predicting infection were created using clinical data, biomarkers, and combined clinical data and biomarker assessments. Integrated discrimination improvement tested the discriminate value of the biomarker and combined models compared with the clinical data model. Results We enrolled 115 patients: 49 determined to have an infection (43%) and 66 without (57%). All biomarkers were significantly associated with infection in univariate analysis. The best clinical model (area under the curve [AUC] = 0.76) included initial temperature (odds ratio [OR], 1.6; confidence interval [CI], 1.1-2.2) and history of fever (OR, 5.0; CI, 1.4-14). The best biomarker model (AUC, 0.82) predicting infection included sE-selectin (OR, 11.0; 95% CI, 1.6-74) and interleukin 6 (OR, 5.1; CI, 2.3-11.6). The combined clinical and biomarker model had an AUC of 0.88, with integrated discrimination improvement = 0.21, compared with the clinical model alone. Conclusion Inflammatory and endothelial markers can improve the clinical identification of infection in ED patients with AVSs.

The Utility of Inflammatory and Endothelial Markers to Identify Infection in Emergency Department Patients.

Identifying infection in emergency department (ED) patients can be challenging. This study assesses the value that inflammatory and endothelial biomarkers add to clinical data when predicting infectious etiologies of abnormal vital signs (AVSs) in ED patients. This study was a prospective, observational cohort study of ED patients with AVSs at an urban, academic tertiary-care hospital, identified from March 1, 2013, to April 15, 2013. Collected blood samples were assayed for soluble E-selectin (sE-selectin), soluble intercellular adhesion molecule 1, vascular cell adhesion molecule 1, plasminogen activator inhibitor 1, interleukin 6, sFlt-1, and procalcitonin. History and physical examination were abstracted from the ED documentation. The primary outcome, infectious etiology, was adjudicated by review of the hospital documentation. Three multivariate logistic regression models predicting infection were created using clinical data, biomarkers, and combined clinical data and biomarker assessments. Integrated discrimination improvement tested the discriminate value of the biomarker and combined models compared with the clinical data model. We enrolled 115 patients: 49 determined to have an infection (43%) and 66 without (57%). All biomarkers were significantly associated with infection in univariate analysis. The best clinical model (area under the curve [AUC] = 0.76) included initial temperature (odds ratio [OR], 1.6; confidence interval [CI], 1.1-2.2) and history of fever (OR, 5.0; CI, 1.4-14). The best biomarker model (AUC, 0.82) predicting infection included sE-selectin (OR, 11.0; 95% CI, 1.6-74) and interleukin 6 (OR, 5.1; CI, 2.3-11.6). The combined clinical and biomarker model had an AUC of 0.88, with integrated discrimination improvement = 0.21, compared with the clinical model alone. Inflammatory and endothelial markers can improve the clinical identification of infection in ED patients with AVSs.

Abstract TP359: One Patient, One Standard, One Medical Record: Improving Documentation of t-PA Therapy across the Care Continuum

Background and Issues: Department specific documentation systems resulted in a non-standardized approach to assessment documentation for patients receiving intravenous t-PA for treatment of acute stroke. Subsequently, compliance with documentation requirements during transition of care from the emergency department (ED) to intensive care unit (ICU) did not meet targeted benchmarks. Purpose: Design a hospital-wide standard and system for vital signs and neuro assessment documentation for patients receiving IV t-PA for the treatment of acute stroke. Methods: A multidisciplinary team analyzed current practice and collaborated to create one standardized documentation record that would satisfy requirements for the ED and the ICU. A t-PA worksheet had proven success with physicians for documenting eligibility and ordering t-PA. The team agreed to keep this worksheet as page one of the documentation record. Page two was designed for ED documentation of medications, assessments and patient response. Page three captures the documentation of mandatory vital signs and neuro assessments. The Stroke Leadership committee approved recommendations from this team for nurses to assess patients using the abbreviated NIH Stroke Scale. Prior to implementation, Physicians and Nurses received education regarding the abbreviated stroke scale and expected documentation. Results: Concurrent monitoring for compliance in documentation of post t-PA vital signs and neuro assessments began with the implementation of this revised documentation record. First month post implementation reported 95% compliance rate and 100% by the fourth month. Conclusions: Process standardization with one consistent documentation tool has sustained 99-100% compliance in documentation of assessments pre and post t-PA administration.

Neurological status in paediatric upper limb injuries in the emergency department – current practice

BackgroundIn upper limb injuries it is important to assess associated neurological injury. The aim of this study was to assess the initial (Emergency Department (ED)) documentation of neurological status in paediatric patients presenting with upper limb injuries.FindingsCase notes of paediatric patients admitted to the orthopaedic ward with upper limb injuries were retrospectively collected over a three month period. Initial ED documentation was recorded and case notes examined for any neurological deficit on admission. Of the 121 patients, 107 (88.4%) of case notes had some form of neurological documentation. The remaining case notes (n = 14, 11.6%) had no mention of neurological examination. There were 10 (8.2%) patients with pre-operative neurological deficits identified; none of these had been previously identified by the ED.ConclusionThere are failings of neurological documentation on the part of ED staff. It is likely that these reflect a knowledge deficit in the examination of the injured upper limb in paediatric patients.

Quality of the handover of patient care: A comparison of Pre-Hospital and Emergency Department notes

The aim of this audit was to evaluate the accuracy of patient information transfer from pre-hospital reports to Emergency Department (ED) documentation. The records of 100 patients seen in the ED resuscitation room of a UK hospital were compared using a pro-forma designed by the research team. Sections of the ambulance service patient report form and the ED documentation were compared for differences. The history of the event leading to the 999 call, the patient's previous medical history, prescribed medications, allergies and any treatment carried out by the ambulance crew were analysed. Of the 100 records, 26 had at least one instance where information recorded by the ambulance crew was either omitted or altered during transfer. These fell into various categories including the previous medical history of the patient, the timings of the event bringing them to hospital, frequency of the event occurring, allergies and medications. This audit quantifies the number of patient encounters where written information changes or is lost when care is passed from pre-hospital to hospital staff in the resuscitation room. We have not investigated other parts of the ED or the verbal transfer of information. Further work investigating the causes of these changes in information, any impact on patient care and whether this occurs in other parts of an ED is suggested.

Randomized Prospective Study to Evaluate Child Abuse Documentation in the Emergency Department

The objective was to determine whether an educational intervention for health care providers would result in improved documentation of cases of possible physical child abuse in children <36 months old treated in the emergency department (ED) setting. This study had a statewide group-randomized prospective trial design. Participating EDs were randomized to one of three intervention groups: no intervention, partial intervention, or full intervention. Medical records for children <36 months of age were abstracted before, during, and after the intervention periods for specific documentation elements. The main outcome measure was the change in documentation from baseline. Generalized estimating equations (GEEs) were used to test for intervention effect. A total of 1,575 charts from 14 hospitals EDs were abstracted. Hospital and demographic characteristics were similar across intervention groups. There were 922 (59%) injury visits and 653 (41%) noninjury visits. For each specific documentation element, a GEE model gave p-values of >0.2 in independent tests, indicating no evidence of significant change in documentation after the intervention. Even among the 26 charts in which the possibility of physical abuse was noted, documentation remained variable. The educational interventions studied did not improve ED documentation of cases of possible physical child abuse. The need for improved health care provider education in child abuse identification and documentation remains. Future innovative educational studies to improve recognition of abuse are warranted.

Emergency department delays in acute stroke – analysis of time between ED arrival and imaging

We determined the factors leading to emergency department (ED) delays in patients with acute stroke. Data were collected prospectively in four Berlin inner-city hospitals by ED documentation, medical records, imaging files and patient interviews. An extended Cox proportional hazards model was fitted to the data. Analyses were performed in 558 patients with confirmed diagnosis of stroke. Median time from admission at ED to beginning of computed tomography/magnetic resonance imaging (CT/MRI) was 108 min. In a subgroup of patients potentially eligible for thrombolysis with a pre-hospital delay <120 min and a National Institutes of Health Stroke Scale (NIHSS) >4 (n = 74), the median interval to imaging was 68 min. Multivariable analysis revealed that a more severe initial NIHSS, a pre-hospital delay <3 h, admission at two specific hospitals, admission at weekends, and private health insurance were significantly associated with reduced delays. In stroke patients, the time interval between ED admission and imaging depends both on factors that emerge from clinical needs and on factors independent of clinical necessities. Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for both improvement of in-hospital management and of medical and non-medical factors influencing pre-hospital delays.

Current gastroenterology

<h3>Background</h3> Our Paediatric Emergency Department (ED) follows a local, multi-specialty designed guideline for the investigation of Urinary Tract Infection (UTI). All children and young people (CYP) presenting with a first proven, or otherwise previously uninvestigated, UTI undergo routine outpatient urinary tract ultrasound (US) imaging. This pathway deviates from National Institute for Health and Care Excellence (NICE) guidance which recommends that children over six months old only undergo imaging if their UTI is atypical or recurrent. The primary aim of this project was to establish the proportion of those undergoing imaging who had a urinary tract abnormality (pre-existing or resultant) requiring specialist referral. We then appraised whether the yield from our investigation pathway justified deviation from NICE guidance. <h3>Method</h3> A retrospective service evaluation was conducted for the period 1 May 2016 to 30 April 2019. Inclusion criteria: all ED-requested US for patients aged 6 months and over with a documented first proven or previously uninvestigated UTI. Exclusion criteria: CYP under six months old; duplicate requests; previous US for UTI; pre-existing UTI follow-up; known pre-existing nephro-urological condition; US indication unrelated to UTI. Patients were identified using the Trust radiology system, with a review of the ED documentation and radiology reports. Reported abnormalities were reviewed against our guideline’s agreed criteria for specialist referral, to determine if follow-up planning was appropriate. <h3>Results</h3> 358 Urinary Tract US were requested during the study period, 161 of which were requested in line with the local UTI guideline. 5 (3.1%) US were not attended but were included in an intention to investigate analysis. 35 (21.7%) patients had nephro-urological abnormalities identified that were referred for general paediatric, urology or nephrology follow-up. An additional 15 (9.3%) patients had US findings that may also have warranted nephro-urological follow-up, giving a potential 50 (31.1%) patients with abnormalities detected outside of NICE guidance. <h3>Conclusion</h3> Up to 31% of patients investigated with US during the three year study period had an abnormality detected that would have remained unidentified if practicing within NICE guidance. Routine US offers a non-invasive, low-risk, low-cost investigative tool to identify nephro-urological abnormalities earlier, improving safety and quality of patient care.