Emergency Department Encounters Research Articles

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

IntroductionOpioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and...

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments.

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

A national analysis of burn injuries among homeless persons presenting to emergency departments

IntroductionBurn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs). MethodsBurn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling. ResultsOf 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021). ConclusionHomeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients’ unique presentation and triage to burn centers accordingly.

Interim Effectiveness of Updated 2023-2024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19-Associated Emergency Department and Urgent Care Encounters and Hospitalization Among Immunocompetent Adults Aged ≥18 Years - VISION and IVY Networks, September 2023-January 2024.

In September 2023, CDC's Advisory Committee on Immunization Practices recommended updated 2023-2024 (monovalent XBB.1.5) COVID-19 vaccination for all persons aged ≥6 months to prevent COVID-19, including severe disease. However, few estimates of updated vaccine effectiveness (VE) against medically attended illness are available. This analysis evaluated VE of an updated COVID-19 vaccine dose against COVID-19-associated emergency department (ED) or urgent care (UC) encounters and hospitalization among immunocompetent adults aged ≥18 years during September 2023-January 2024 using a test-negative, case-control design with data from two CDC VE networks. VE against COVID-19-associated ED/UC encounters was 51% (95% CI = 47%-54%) during the first 7-59 days after an updated dose and 39% (95% CI = 33%-45%) during the 60-119 days after an updated dose. VE estimates against COVID-19-associated hospitalization from two CDC VE networks were 52% (95% CI = 47%-57%) and 43% (95% CI = 27%-56%), with a median interval from updated dose of 42 and 47 days, respectively. Updated COVID-19 vaccine provided increased protection against COVID-19-associated ED/UC encounters and hospitalization among immunocompetent adults. These results support CDC recommendations for updated 2023-2024 COVID-19 vaccination. All persons aged ≥6 months should receive updated 2023-2024 COVID-19 vaccine.

Relationship between on-demand telehealth visits and emergency department and hospital surge during the COVID-19 pandemic.

The relationship between COVID-19-related telehealth calls could be used to predict emergency department visits and hospital surges 3 days later potentially facilitating staffing adjustments in advance of patient arrivals. The purpose of this research was to study the temporal association between frequencies of on demand telehealth calls and emergency department surges during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. This cohort study examined patients who self-initiated synchronous audio-video on-demand telehealth calls between January 1, 2020 and June 30, 2022, and compared these to emergency department arrivals. The exposure in question was a synchronous audio-video on-demand telehealth visit. Our main outcome measured was frequency of emergency department visits. After autocorrelation, a multivariate linear regression model was utilized to determine temporal relationships between the two variables. This cohort study examined 42,429 synchronous audio-video on-demand telehealth calls, of which 43.6% were COVID-19 related, and 540,686 emergency department visits, of which 3.9% were diagnosed with COVID-19. COVID-19-related telehealth calls 3 days prior were predictive of emergency department encounters (r 2=0.85, p<0.001). Emergency department encounters were strongly correlated with hospital admissions (r 2=0.71, p<0.001). Our results demonstrate that telehealth calls related to COVID-19 were an accurate predictor of emergency department encounters 3 days later, and emergency department encounters are highly correlated with hospital admissions. Limitations include that we only assessed a single health system in the region covered by the telemedicine healthcare professionals. We did not examine direct links between these two encounter types nor severity of illness at the patient level. Understanding that telehealth calls related to COVID-19 are highly predictive of emergency department encounters within 3 days may provide a brief but important window to upstaff hospitals at the beginning of future COVID-19 surges.

Diagnosis and Treatment of Pneumonia in Urgent Care Clinics: Opportunities for Improving Care.

Community-acquired pneumonia is a well-studied condition; yet, in the urgent care setting, patient characteristics and adherence to guideline-recommended care are poorly described. Within Intermountain Health, a nonprofit integrated US health care system based in Utah, more patients present to urgent care clinics (UCCs) than emergency departments (EDs) for pneumonia care. We performed a retrospective cohort study 1 January 2019 through 31 December 2020 in 28 UCCs within Utah. We extracted electronic health record data for patients aged ≥12 years with ICD-10 pneumonia diagnoses entered by the bedside clinician, excluding patients with preceding pneumonia within 30 days or missing vital signs. We compared UCC patients with radiographic pneumonia (n = 4689), without radiographic pneumonia (n = 1053), without chest imaging (n = 1472), and matched controls with acute cough/bronchitis (n = 15 972). Additional outcomes were 30-day mortality and the proportion of patients with ED visits or hospital admission within 7 days after the index encounter. UCC patients diagnosed with pneumonia and possible/likely radiographic pneumonia by radiologist report had a mean age of 40 years and 52% were female. Almost all patients with pneumonia (93%) were treated with antibiotics, including those without radiographic confirmation. Hospital admissions and ED visits within 7 days were more common in patients with radiographic pneumonia vs patients with "unlikely" radiographs (6% vs 2% and 10% vs 6%, respectively). Observed 30-day all-cause mortality was low (0.26%). Patients diagnosed without chest imaging presented similarly to matched patients with cough/acute bronchitis. Most patients admitted to the hospital the same day after the UCC visit (84%) had an interim ED encounter. Pneumonia severity scores (pneumonia severity index, electronic CURB-65, and shock index) overestimated patient need for hospitalization. Most UCC patients with pneumonia were successfully treated as outpatients. Opportunities to improve care include clinical decision support for diagnosing pneumonia with radiographic confirmation and development of pneumonia severity scores tailored to the UCC.

Nurse-focused ultrasound-guided IV program improves core emergency department process measures.

Ultrasound-guided peripheral IV catheter (USGIV) insertion is as an effective procedure to establish access in patients with difficult intravenous access (DIVA), a condition frequently encountered in the Emergency Department (ED). This study describes a DIVA quality improvement program focusing on rapid identification of DIVA patients and emergency nurse USGIV training and evaluates its impact on overall frequency of USGIV use and process measures related to quality of patient care. This is a retrospective cohort study of patients over 18 years of age, presenting to a single, tertiary care hospital between September 1, 2018 and September 30, 2020. Difference-in-difference analysis was used to compare ED process measures pre- and post-implementation of the DIVA Program, and multivariate logistic regression was used to identify associations between patient characteristics and difficult IV access. The frequency of ED encounters associated with USGIV placement more than doubled post-implementation of the DIVA Program, rising from 606 to 1323. There were improved covariate-adjusted time estimates of core ED process measures for encounters associated with USGIV placement post-implementation, including decreases in time to CT with contrast from 4.8 h (95% CI = 4.4-5.2) to 4.1 h (95% CI = 3.8-4.4), pain medications from 2.4 h (95% CI = 2.1-2.6) to 1.8 h (95% CI = 1.6-2.0), IV antibiotics from 3.0 h (95% CI = 2.4-3.7) to 2.1 h (95% CI = 1.5-2.6), and ED length of stay from 6.4 h (95% CI = 6.2-6.6) to 6.0 h (95% CI = 5.9-6.2). A nurse-focused quality improvement program focused on teaching and promoting USGIV as a modality for managing difficult IV access was associated with increases in USGIV placement and improvements in core process measures related to quality of patient care.

Proposing the "Continuum of UTI" for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections.

Patients with suspected UTIs are categorized into 3 clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach. This was a retrospective cohort study of a random sample of adult noncatheterized inpatient and emergency department encounters with paired urinalysis and urine cultures from 5 hospitals in 3 states between January 01, 2017, and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the continuum of UTI, a 5-level classification scheme that includes 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance. The newly defined continuum of UTI categories were compared to the current UTI classification scheme. Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the continuum of UTI categories, 68% of patients (n = 478) with ASB were reclassified as bacteriuria of unclear significance and 29% of patients (n = 467) with "no UTI" were reclassified to lower urinary tract symptoms/other urologic symptoms. Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by frontline clinicians, and promote a nuanced approach to diagnosis and management of UTIs.

Resource Use and Clinical Outcomes in Infants with Supraventricular Tachycardia Monitored with the Owlet Smart Sock

ObjectivesTo describe the prevalence of Owlet Smartsock (OSS) use in infants with supraventricular tachycardia (SVT), and associated demographic and clinical characteristics of users, and to analyze the association of OSS use on medical resource utilization and clinical outcomes from emergency department (ED) encounters for SVT. Study designSingle-center, retrospective cohort study of infants with confirmed SVT, from 2015 to 2022. OSS users and non-users were compared across clinical and demographic parameters. Medical resource utilization (phone calls, office visits, ED visits) and outcomes (need for intensive care, length of stay, echocardiographic function, clinical appearance) were compared between OSS users and non-users. ResultsOf 133 infants with SVT, OSS was used by 31/133 (23%), purchased prior to SVT diagnosis in 5/31 (16%) of users. No demographic difference was found between OSS users and non-users. OSS users had more phone notes than non-users, (p =0.002) and more ED visits, (p=0.03) but the number of office visits and medication adjustments did not differ. During ED presentation, OSS users had better preserved left ventricular ejection fraction on echocardiogram (p=0.04) and lower length of hospital stay by a mean 1.7 days (p=0.02). ConclusionOSS is used by a portion of infants with SVT. It is associated with more frequent phone calls and ED visits, but lower length of stay and better-preserved cardiac function upon presentation.

Abstract WP66: Increases in Emergency Department Utilization of CT Angiography Brain and CT Perfusion in the Transferred Patient Population Across the Endovascular Therapy Era

Background: With the advent of endovascular therapy as a treatment modality for LVO stroke, the importance of stroke networks has become increasingly clear. We sought to understand the way advanced neuroimaging is utilized in transferred emergency department (ED) encounters using a large national dataset. Methods: Retrospective cohort study of adult ED encounters, comparing ED transfers (to other acute care hospitals) to discharged patients. Data from the 2013-2018 National Emergency Department Sample (NEDS), an AHRQ dataset containing a weighted 20% sample of US ED encounters were analyzed. CTA Head, CTP, MRI Brain, and Non-contrast CT Head imaging use was determined from Common Procedural Terminology (CPT) codes. ICD10 Codes I60-I69 were used to indicate cerebrovascular disease. Statistical comparisons used 95% CI for rate per 100,000 ED visits. Results: ED utilization of advanced neuroimaging was higher in transferred patients than discharged patients in all years studied (Fig). Between 2013 and 2018, utilization of CTA and CTP increased 8-fold and 20-fold, respectively in the transferred population. Noncontrast head CT and MRI were relatively stable but more frequent in transferred encounters. Between 2013 and 2018, encounters associated with a transfer came disproportionately from smaller hospitals (45% from hospitals with &lt;=20,000 ED visits per year, and 24% from ED visits at hospitals with between 20,000 and 40,000 ED visits per year). In 2018 transferred encounters with a CTA Head or CTP, 75% (72-77) and 76%(70-83), respectively had a diagnosis code associated with cerebrovascular disease. Conclusions: Utilization of CTA and CTP increased substantially between 2013-2018 in the ED transfer population, and most of these encounters are associated with a cerebrovascular disease diagnosis. Detailed diagnosis and hospital demographic data to be presented. These results have implications for the design and optimization of stroke systems of care.

Impact of the COVID-19 Pandemic on Healthcare Utilization among Medically Underserved Patients with Ambulatory Care Sensitive Conditions.

This study aims to examine (1) the impact of the pandemic phases on overall and preventable hospitalizations and emergency department (ED) visits, and (2) the effect of the pandemic on these outcomes within subgroup populations including gender, race, patients' residence in health professional shortage areas (HPSA), and residence in a federal poverty level. We used electronic medical record (EMR) data for the year 2019 and 2020 from a large health system predominantly serving medically underserved patients in the South. We used a difference-in-differences approach to examine changes in weekly rates of overall and preventable hospitalizations and ED visits in the pandemic phase 1 (Mid-March to June of 2020) and phase 2 (July-September of 2020) compared to the same period in 2019 after adjusting for weekly outcome rates in the baseline period (January to Mid-March of 2020) compared to the same period in 2019. The study sample included 1.4 million hospitalizations and ED encounters. In phase 1 of the pandemic, there were significant reductions in overall (-108) and preventable (-75.3) hospitalizations, and overall (-408) and preventable (-306) ED visits when compared to the same period in 2019. In phase 2 of the pandemic, there were significant reductions in overall (-60) and preventable (-43) hospitalizations and in overall (-360) and preventable (-258) ED visits as compared to 2019. We found greater reductions in ED visits, both overall and preventable, during the early pandemic phases among Black patients than among White patients. Similar patterns in the reduction of ED visits were found in Black versus White patients within subgroups of women, men, and those residing in a HPSA and low-income areas. Substantial reductions in utilization were observed in Black patients in comparison to white patients and these differences persisted among men, women, and those living in underserved and low-income areas.

Abstract 134: Thrombotic Complications of Ovarian Hyperstimulation Syndrome

Introduction: Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of ovarian stimulation used during assisted reproductive technology cycles. In severe OHSS, increases in capillary permeability can result in hemoconcentration and hypercoagulability leading to thrombotic events, including stroke and cerebral venous thrombosis. Herein we sought to determine the prevalence of hospitalization for thrombotic events shortly after OHSS using population-level data. Methods: We conducted two separate retrospective cohort studies of patients with OHSS using publicly available datasets: (1) administrative claims data from the Healthcare Cost and Utilization Project (HCUP) across 11 states from 2016 to 2020 and (2) National Inpatient Sample (NIS) registry data from the end of 2015 to 2020. HCUP contains both emergency department and inpatient encounters whereas NIS contains a nationally representative sample of inpatient encounters. For our study, all female patients with an encounter for OHSS, defined using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code N98.1 were included from each dataset. Our primary study outcome was any stroke or major thrombotic event identified within 60 days of OHSS diagnosis in HCUP or during the index admission for OHSS in NIS. We used previously validated ICD-10-CM codes for acute ischemic stroke, intracerebral and subarachnoid hemorrhage, cerebral venous thrombosis, acute myocardial infarction, pulmonary embolism, and acute deep venous thrombosis to define our study outcome. Results: We identified a total of 747 patients with OHSS in HCUP. Within the HCUP cohort, fewer than 10 patients (&lt;1%) were hospitalized with a stroke or thrombotic event within 60 days of OHSS diagnosis. There were 1,955 hospitalizations for OHSS in NIS. There were 20 (1%) pulmonary embolisms and 35 (1.8%) acute deep venous thromboses, but no other stroke/thrombotic complications in NIS. Conclusions: We found very few thrombotic events shortly after OHSS diagnosis using two large datasets. The low rate of outcome events after OHSS seen in each of our population-level analyses increases the reliability of these study results.

An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department

There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV. This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening. The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%. An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing. Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients.

Second- and third-year medical students' clinical encounters in the emergency department.

Experiential learning theory suggests that direct clinical experiences facilitate learning. Previous literature has focused primarily on the experiences of fourth-year medical students. As more students gain early clinical exposure, it is important to understand the types of patients seen by junior students. This study aims to categorize the clinical experiences of early (M2 and M3) students in the emergency department (ED). A retrospective review of the electronic health record of patients seen by M2s and M3s on a 2-week emergency medicine rotation at a single urban academic ED in the Midwest was performed. Data elements extracted included total number of patients seen, Emergency Severity Index (ESI), disposition, and chief complaint. Students were not mandated to see any particular patients. Medical students (248) saw 2994 total patients from 2018 to 2022. The median number of patients seen by each student was 12.0 (range 1-32). Pediatric patients made up 6.5% (n = 194) of total patients. Encounters were primarily ESI 2 or 3, which accounted for 89.4% of all patients (n = 2676). The most encountered complaints were abdominal pain, chest pain, and dyspnea, making up 15.6% (n = 467), 8.7% (n = 260), and 5.5% (n = 165), respectively, of total cases. Obstetrics/gynecology, hematologic, and environmental disorders were the least frequently encountered domains. No students saw all Clerkship Directors in Emergency Medicine (CDEM)-recommended complaints. There is significant variability in the ED encounters of M2s and M3s, with wide ranges of patient volume and presentations. This study provides some evidence that early students may not be meeting CDEM recommendations.

Sepsis Prediction at Emergency Department Triage Using Natural Language Processing: Retrospective Cohort Study.

Despite its high lethality, sepsis can be difficult to detect on initial presentation to the emergency department (ED). Machine learning-based tools may provide avenues for earlier detection and lifesaving intervention. The study aimed to predict sepsis at the time of ED triage using natural language processing of nursing triage notes and available clinical data. We constructed a retrospective cohort of all 1,234,434 consecutive ED encounters in 2015-2021 from 4 separate clinically heterogeneous academically affiliated EDs. After exclusion criteria were applied, the final cohort included 1,059,386 adult ED encounters. The primary outcome criteria for sepsis were presumed severe infection and acute organ dysfunction. After vectorization and dimensional reduction of triage notes and clinical data available at triage, a decision tree-based ensemble (time-of-triage) model was trained to predict sepsis using the training subset (n=950,921). A separate (comprehensive) model was trained using these data and laboratory data, as it became available at 1-hour intervals, after triage. Model performances were evaluated using the test (n=108,465) subset. Sepsis occurred in 35,318 encounters (incidence 3.45%). For sepsis prediction at the time of patient triage, using the primary definition, the area under the receiver operating characteristic curve (AUC) and macro F1-score for sepsis were 0.94 and 0.61, respectively. Sensitivity, specificity, and false positive rate were 0.87, 0.85, and 0.15, respectively. The time-of-triage model accurately predicted sepsis in 76% (1635/2150) of sepsis cases where sepsis screening was not initiated at triage and 97.5% (1630/1671) of cases where sepsis screening was initiated at triage. Positive and negative predictive values were 0.18 and 0.99, respectively. For sepsis prediction using laboratory data available each hour after ED arrival, the AUC peaked to 0.97 at 12 hours. Similar results were obtained when stratifying by hospital and when Centers for Disease Control and Prevention hospital toolkit for adult sepsis surveillance criteria were used to define sepsis. Among septic cases, sepsis was predicted in 36.1% (1375/3814), 49.9% (1902/3814), and 68.3% (2604/3814) of encounters, respectively, at 3, 2, and 1 hours prior to the first intravenous antibiotic order or where antibiotics where not ordered within the first 12 hours. Sepsis can accurately be predicted at ED presentation using nursing triage notes and clinical information available at the time of triage. This indicates that machine learning can facilitate timely and reliable alerting for intervention. Free-text data can improve the performance of predictive modeling at the time of triage and throughout the ED course.

Rate of Successful Shoulder Reduction on First Confirmatory Imaging in the Emergency Department

BackgroundManagement of acute shoulder dislocation in the emergency department (ED) is common. ObjectiveThis study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED. MethodsThe study was a retrospective case–control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts. ResultsOf 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2–22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6–84.3%] vs. 68.0% [95% CI 56.8–77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6–97.3%] vs. 84.0% [95% CI 74.4–91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8–47.6%] vs. 29.3% [95% CI 19.9–40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4–31.0%] vs. 45.3% [95% CI 34.4–56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001). ConclusionsThe rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.

Characterizing emergency department and inpatient health care utilization after seizure-related hospitalization: A retrospective cohort study.

Seizure care is a significant driver of health care costs in both emergency department (ED) and inpatient settings, but the majority of studies have focused on inpatient admissions as the only metric of health care utilization. This study aims to better characterize ED and inpatient encounters among patients with seizure to inform care and policy. Using statewide administrative data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from Florida and New York, we identified patients with a seizure-related index hospitalization between January 1, 2016, and December 31, 2018. Among this cohort, we examined the incidence and characteristics of subsequent acute care visits in the ED and inpatient settings for 365 days after initial hospital discharge. A total of 54 456 patients had an eligible seizure-related hospitalization. Patients were 49% female, predominantly White (64%) and non-Hispanic (84%), and used a public primary payer (68%). There were 36 838 (68%) patients with at least one acute care visit in the year following discharge. Overall, patients had a median of 2 (interquartile [IQR] = 1-5) subsequent acute care visits and the median time to first acute care visit was 53 days (IQR = 15-138). Of the 154 369 subsequent acute care visits, 97 399 (63%) were ED-only visits, 56 970 (37%) were readmissions, and 37 176 (24%) were seizure-related. There were 18 786 patients (35%) with four or more acute care visits over 365 days of follow-up. Patients with four or more visits contributed 84% of acute care visits and 78% of costs after initial hospitalization. The majority of patients hospitalized for seizure return to the ED or hospital at least once in the year after discharge. A small portion of patients account for the majority of ED and inpatient visits as well as health care costs associated with this population, identifying a subgroup of patients who may benefit from improved inpatient and outpatient management.

Neighborhood Disadvantage and Healthcare Utilization in Pediatric Sickle Cell Patients

Background: Sickle cell disease (SCD) is a complex heritable blood disorder associated with higher acute healthcare utilization further complicated by psychosocial and socioeconomic factors. Other studies have indicated a relationship between neighborhood disadvantage and increased healthcare utilization. We hypothesize that those with greater neighborhood disadvantage will have greater acute healthcare utilization.&#x0D; Methods: Data was collected retrospectively from the electronic medical record between 9/30/2021 and 7/11/2023 for patients followed at Riley Hospital for Children’s Pediatric SCD Clinic who completed a psychosocial needs assessment (PAT). Number of emergency department (ED) visits, hospitalizations, and missed clinic visits were collected from the time the PAT was completed up to 1 year after (or the end of the data collection period). Data regarding area deprivation index (ADI) and childhood opportunity index (COI) were collected utilizing patient home address. Descriptive statistics were performed on all data above, as well as t-tests and chi square tests for univariate analyses.&#x0D; Results: 142 patients completed a PAT during the study period. 88% had a primary care provider documented, and 73% had public insurance. The median state and national ADI (6, 76.5) and COI (2, 2) demonstrated greater neighborhood disadvantage and less childhood opportunity. There was no statistically significant difference between ADI or COI and number of ED encounters or hospitalizations. However, patients who missed 1 or more SCD visits had a higher median state ADI than those who did not miss a visit (7.5 vs 5, p=0.002). Median state COI was also lower in this group than those who did not miss a visit (1 vs 2, p=0.001).&#x0D; Conclusion: Those with higher ADI and lower COI could benefit from more directed support to improve access to preventative care visits. Further analysis accounting for comorbidities (seizures, asthma, depression) could disambiguate a relationship between ADI or COI and acute care utilization.

Concordance in Medical Urgency Classification of Discharge Diagnoses and Reasons for Visit

Current policies to divert emergency department (ED) visits for less medically urgent conditions to more cost-effective settings rely on retrospective adjudication of discharge diagnoses. However, patients present to the ED with concerns, making it challenging for clinicians. To characterize ED visits based on the medical urgency of the presenting reasons for visit and to explore the concordance between discharge diagnoses and reasons for visit. In this retrospective, cross-sectional study, a nationwide sample of ED visits by adults (aged ≥18 years) in the US from the 2018 and 2019 calendar years' ED data of the National Hospital Ambulatory Medical Care Survey was used. An algorithm to probabilistically assign ED visits into medical urgency categories based on the presenting reason for visit was developed. A 3-step, look-back method was applied using an updated version of the New York University ED algorithm, and a map of all possible discharge diagnoses to the same reasons for visit was developed. Analyses were conducted in July and August 2023. The main outcome was probabilistic medical urgency classification of reasons for visits and discharge diagnoses and their concordance. We analyzed 27 068 ED visits (mean age, 48.2% years [95% CI, 47.5%-48.9% years]) representing 190.7 million visits nationwide. Women (mean, 57.0% [95% CI, 55.9%-58.1%]) and patients with public health insurance coverage, including Medicare (mean, 24.9% [95% CI, 21.9%-28.0%]) and Medicaid (mean, 25.1% [95% CI, 21.0%-29.2%]), accounted for the largest share of ED visits, and a mean of 13.2% (95% CI, 11.4%-15.0%) of all visits resulted in a hospital admission. Overall, about 38.5% and 53.9% of all ED visits were classified with 100% and 75% probabilities, respectively, as injury related, emergency care needed, emergent but primary care treatable, nonemergent, or mental health or substance use disorders related based on discharge diagnosis compared with 0.4% and 12.4%, respectively, of all encounters based on patients' reason for visit. Among discharge diagnoses assigned with high certainty to only 1 urgency category using the New York University ED algorithm, between 38.0% (95% CI, 36.3%-39.6%) and 57.4% (95% CI, 56.0%-58.8%) aligned with the probabilistic categorical assignments of their corresponding reasons for visit. In this cross-sectional study of 190.7 million ED visits among adults aged 18 years or older, a smaller percentage of reasons for visit could be prospectively categorized with high accuracy to a specific medical urgency category compared with all visits based on discharge diagnoses, and a limited concordance between reasons for visit and discharge diagnoses was found. Alternative methods are needed to identify the medical necessity of ED encounters more accurately.

Evaluating Risk Factors for Developing Hypoglycemia During Treatment of Hyperkalemia With Intravenous Regular Insulin

Background: The conventional dose of 10 units of intravenous (IV) regular insulin to treat hyperkalemia has been associated with hypoglycemia. There have been retrospective studies evaluating weight-based dose vs conventional dose of IV regular insulin but the comparative efficacy and safety is not well established. Objective: Evaluate the difference in weight-based dosing of IV regular insulin between patients who experienced hypoglycemia vs. patients who did not experience hypoglycemia after the administration of IV regular insulin. Methods: This was a retrospective, electronic chart review at a single academic medical center which included patients ≥18 years of age with an emergency department or inpatient encounter who were administered IV regular insulin within 6 hours of a pre-treatment potassium of ≥5 mmol/L. Results: There was no significant difference in the weight-based insulin dose between patients who experienced a hypoglycemic event and patients who did not experience a hypoglycemic event (.14 vs .22 units/kg; P = .44). The potassium-lowering effect was similar between the two groups (1.02 vs .96 mmol/L; P = .56). A regression analysis revealed that female sex, low baseline blood glucose (glucose <140 mg/dL), and those who received a repeat dose of IV regular insulin were independent risk factors for development of hypoglycemia. Conclusion: This study found no difference in hypoglycemic events and potassium lowering based on IV weight-based regular insulin dosing, however other risk factors may predict hypoglycemia.