Emergency Department Encounters Research Articles

Wound Characteristics Among Patients Exposed to Xylazine.

The alpha-2 agonist xylazine is increasingly detected as an adulterant in illicitly manufactured fentanyl. There is concern that xylazine may be responsible for an emerging pattern of necrotizing wounds among people who use drugs, but the clinical features of wounds associated with xylazine remain poorly characterized. To systematically characterize the location, wound bed surface, and chronicity of wounds among persons with confirmed xylazine exposure. This case series at 3 academic medical hospitals in Philadelphia, Pennsylvania, included patients with emergency department or inpatient encounters from April 2022 to February 2023 who had a wound-related chief complaint and xylazine detected with urine gas chromatography-mass spectroscopy. Xylazine. The location, size, wound bed, and chronicity of wounds associated with xylazine using electronic medical record abstraction and Fisher exact tests. Of 59 wounds from 29 unique patients with confirmed xylazine exposure (mean [SD] age, 39.4 [8.8] years; 15 [52%] male; all using fentanyl, and 23 [79%] routinely injecting opioids), 53 wounds (90%) were located on extremities, and 41 (69%) involved extensor surfaces. Five wounds (9%) involved exposed deep structures such as bone or tendon. Of 57 wounds with photographs, 34 (60%) had wound beds of predominantly devitalized tissue (eschar or slough). Based on patient report, 28 wounds (48%) were acute (<1 month old), 12 (20%) were subacute (present for 1-3 months), and 17 (29%) were chronic (developed ≥3 months prior). Subacute and chronic wounds were more often medium or large in size (odds ratio, 48.5; 95% CI, 8.2-1274.8; P < .001) and more frequently had devitalized wound beds (odds ratio, 9.5; 95% CI, 2.9-37.0; P < .001). In this case series of hospitalized patients with confirmed xylazine exposure, wounds were commonly located on extensor surfaces of the extremities, frequently had devitalized tissue or exposed deep structures, and were more likely to have larger and necrotic wound beds the longer they had persisted. This systematic characterization of xylazine-associated wounds may inform identification, management, and research to address this emerging public health threat.

Clinical and demographic factors linked to low-value emergency department visits in pediatric patients with spina bifida.

Identifying factors associated with emergency visits that could be delivered at lower-cost sites may help guide population health strategies for pediatric patients with spina bifida. Emergency department encounters (2016-2023) by patients with spina bifida (< 18-years-old) in Pediatric Health Information System were identified. Absence of clinical and imaging charges was defined as low-value emergency visit. We utilized a control population of patients (<18-years-old) with obstructive/reflux uropathy who presented for emergency department encounters (2016-2023). Mixed effects (with repeated individual measurements as random effect) logistic regression was fitted to model odds of low-value emergency visit. In total, we included 22,672 emergency visits by patients with spina bifida. 20.7% of these emergency visits were low-value versus 17.7% in controls (p<0.001). Costs related to low-value emergency visits account for 3.8% of all costs for emergency visit-related encounters in patients with spina bifida. Low-value emergency visits were associated with younger age [OR 1.05 (1.04 - 1.06) per year younger], Hispanic/Latino [OR 1.21 (1.06 - 1.39) compared to non-Hispanics], black [OR 1.35 (1.16 - 1.58) compared to white], public insurance [OR 1.14 (1.01 - 1.29) compared to private insurance], and genitourinary encounter diagnosis [OR 1.16 (1.04 - 1.30)]. Using a standard patient, we found that the odds of low-value emergency visit across hospitals ranged from 0.31 to 5.36. Younger age, Hispanic/Latino ethnicity, black and other race, public insurance, and genitourinary encounter diagnosis were associated with higher odds for low-value emergency visits in pediatric patients with spina bifida. There was wide variation across hospitals that warrants further investigation to elucidate best practices.

Epidemiology of Emergency Department Visits for Children With Clinically Significant Cardiovascular Disease.

The aim of the study is to determine the epidemiology, cost, and factors associated with hospital admission, deterioration if hospitalized, and mortality for children with a history of clinically significant cardiovascular disease (CVD) presenting to pediatric emergency departments (EDs). Using the Pediatric Health Information System, we performed a retrospective analysis of ED encounters of children ≤17 years old with clinically significant CVD between 2016 and 2021. Patients were included if they had a cardiovascular complex chronic condition, defined by ICD diagnosis, and procedure codes. We assessed the primary diagnosis, admission rate, ICU transfer rate (as a marker of disease progression), mortality, resource utilization, and costs. We conducted multivariable analyses to identify risk factors for admission, ICU transfer, and mortality. There were 201,551 ED visits (mean 33,592 ± 3354 per year) among 129,938 children with clinically significant CVD. Most ED encounters had a primary diagnosis of a circulatory (21.1%) or respiratory (19.7%) illness. Seventy-six percent of visits had at least one blood test or imaging study conducted. The overall admission rate was 59.7%, with 28.7% admitted to the ICU, and 6.2% transferred to the ICU after the first 24 hours. The median costs for encounters resulting in admission were $13,605 in US 2023 dollars. In multivariable analyses, younger age, a greater number of noncardiac complex chronic conditions, and CVD type were associated with increased odds of admission, ICU transfer after 24 hours, and mortality (all P < 0.05). ED visits for children with clinically significant CVD lead to substantial resource utilization, including frequent hospitalization, ICU level of care, and costs. This baseline data aids in the development of prospective studies to inform the appropriate ED management for children with clinically significant CVD.

Sociodemographic predictors of imaging utilization in children with right lower quadrant pain.

Inequities in health care access lead to inequities in outcome. In recent years, health outcome disparities have been documented in children with acute appendicitis and sociodemographic predictors of imaging utilization have not been adequately assessed. The purpose of our study is to assess sociodemographic predictors for the diagnostic imaging of children with right lower quadrant (RLQ) pain. Our hypothesis is that disparities exist in imaging utilization. Our nationwide retrospective cohort study of the Pediatric Health Information System (PHIS) database queried emergency department encounters for children aged 0-18years presenting with RLQ pain (ICD code CM R10.31) between January 2018 and September 2023. Primary exposures included neighborhood-level sociodemographic metrics as measured by Child Opportunity Index, race/ethnicity, and insurance status. Outcomes included no diagnostic imaging, diagnostic imaging with radiography alone, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Multivariable logistic regression analyses assessed modality usage with respect to the primary exposures after controlling for demographic (age, gender) and additional (hospital geographic region, time of imaging) covariates. To avoid the perpetuation of bias, reference categories were determined by the lowest numerical value for each covariate. In total, 100,161 patient encounters met inclusion criteria (mean patient age 11.2years ± 3.9; 59.3%, n = 59,416 females). Imaging utilized was US (78.0%; n = 78,115), CT (16.4%, n = 16,405), no imaging (13.9%, n = 13,894), radiography alone (4.4%, n = 4,429), and MRI (3.1%, n = 3,148). The most predictive factors for no imaging were moderate, low, and very low Child Opportunity Index (aOR 1.25, 1.17, and 1.18 [95% CI 1.10-1.33] compared to very high Child Opportunity Index); Black race/ethnicity (aOR 1.26 [95% CI 1.11-1.44] compared to White or Asian race/ethnicity); and public or other insurance (aOR 1.23 and 1.32 [95% CI 1.18-1.41] compared to commercial insurance). The most predictive factors for radiography alone were Black race/ethnicity (aOR 1.30 [95% CI 1.17-1.45] compared to Hispanic race/ethnicity) and public or other insurance (aOR 1.26 [95% CI 1.11-1.44] compared to commercial). The most predictive factors for US were very-high Child Opportunity Index (aOR 1.16 [95% CI 1.09-1.22] compared to very low Child Opportunity Index); Asian, NH-White, or Hispanic race/ethnicity (aOR 1.33, 1.31, 1.30 [95% CI 1.18-1.40] compared to Black race/ethnicity); and commercial insurance (aOR 1.20 [95% CI 1.16-1.25] compared to public insurance). The most predictive factor for CT was White race/ethnicity (aOR 1.26 [95% CI 1.11-1.43] compared with Asian race/ethnicity) and the most predictive factor for MRI was Hispanic race/ethnicity (aOR 1.49 [95% CI 1.17-1.61] compared with Black race/ethnicity). The greatest predictor of cross-sectional imaging was a hospital's region, with CT most likely in southern hospitals (aOR 4.09 [95% CI 2.17-7.70] compared with northeast hospitals). Patient Child Opportunity Index did not predict the likelihood of cross-sectional imaging with CT or MRI in tertiary pediatric centers. Sociodemographic disparities exist in the imaging of children presenting to tertiary pediatric hospitals with RLQ pain. Future studies are needed to analyze the causes of such disparities both on hospital and departmental levels.

Comparing imputation approaches for immigration status in ED visits: Implications for using electronic medical records.

This study aimed to compare imputation approaches to identify the likely undocumented patient population in electronic health record (EHRs). EHR are a promising source of information on undocumented immigrants' medical needs and care utilization, but there is no verified way to identify immigration status in the data. Different approaches to approximating immigration status in EHR introduce unique biases, which in turn has major implications on our understanding of undocumented immigrant patients. We used a dataset of all emergency department (ED) visits from 2016 to 2019 in the Los Angeles Department of Health Services (LADHS) merged across patient medical records, demographic data, and claims data. We included all ED visits from our patient groups of interest and limited to patients at or over the age of 18 years at the time of their ED visit and excluded empty encounter records (n = 1,106,086 ED encounters). We created three patient groups: (1) US-born, (2) foreign-born documented, and (3) undocumented using two different imputation approaches: a logical approach versus statistical assignment. We compared predicted probabilities for two outcomes: an ED visit related to a behavioral health (BH) disorder and inpatient admission/transfer to another facility. Both approaches provide comparable estimates among the three patient groups for ED encounters for a BH disorder and inpatient admission/transfer to another facility. Undocumented immigrants are less likely to have a BH diagnosis in the ED and are less likely to be admitted or transferred compared to the US-born. Researchers should consider expanding EHR with administrative data when studying the undocumented patient population and may prefer a logical approach to estimate immigration status. Researchers who rely on payer status alone (i.e., restricted Medicaid) as a proxy for undocumented immigrants in EHR should consider how this may bias their results. As Medicaid expands for undocumented immigrants, statistical assignment may become the preferred method.

Subconjunctival Hemorrhages Are Rare Among Infants With Cough and Gastrointestinal Conditions.

Subconjunctival hemorrhages (SCHs) are uncommon injuries in young children beyond the neonatal period and have been associated with abuse. In otherwise well infants, they are sometimes attributed to commonly observed symptoms that invoke Valsalva maneuvers, such as cough, vomiting, and constipation. Our study aims to ascertain the prevalence of SCH among children presenting to emergency care with cough, vomiting, and constipation. We conducted a cross-sectional secondary analysis of a prospectively collected dataset of children aged 1 month to 3 years presenting to a tertiary pediatric emergency department (ED). Children with and without SCH were identified at the time of their examination by ED providers. Children were assigned to Valsalva symptom groups of cough, vomiting, and/or constipation based on review of the ICD-10 codes associated with the ED encounter. Descriptive statistics and prevalence were calculated for each group. Chi-square testing of proportions was used to compare the prevalence of SCH based on the presence or absence of the 3 symptoms of interest. Four thousand seven hundred seventeen qualifying ED encounters were captured, with 2 total cases of SCH identified (0.4 per 1000). SCHs were uncommonly observed in patients with cough (0.5 per 1000), vomiting (0 per 1000), and constipation (0 per 1000). We found no significant differences in the prevalence of SCH based on the presence or absence of cough (P = 0.87), vomiting (P = 0.52), or constipation (P = 0.82). SCH is an uncommon finding in children under 3 years and is similarly uncommon among children with cough, vomiting, or constipation. It should not be attributed to uncomplicated presentations of cough, vomiting, or constipation, and alternative diagnoses, including abuse, should be carefully considered in the differential diagnosis of SCH.

Sociodemographic Disparities in 1-Year Outcomes of Children With Community-Acquired Acute Kidney Injury

Racial disparities have been identified in pediatric community-acquired acute kidney injury (CA-AKI), and they are associated with increased risk of child mortality, morbidity, and progression of kidney disease. To assess clinical outcomes at 1 year among children with CA-AKI, stratified by age, race, and ethnicity. This retrospective cohort study is a population-based analysis of deidentified, aggregated electronic health record data collected by 61 large health care organizations from 2003 to 2023 and accessed through the TriNetX platform. Outcomes were assessed at 1 year after a CA-AKI episode. Participants included pediatric patients (aged <18 years) with AKI. Data were accessed in January 2024. A diagnosis of CA-AKI and sociodemographic factors such as race, ethnicity, and age, as reported in electronic health records. The primary end point of this study was to assess differences in clinical outcomes within 1 year of an episode of CA-AKI, including all-cause emergency department (ED) visits, intensive care unit (ICU) admissions, mechanical intubation and ventilation, and mortality. Risk was compared between White children and Asian (including Asian, Native Hawaiian, and Other Pacific Islander), Black, and Hispanic children, stratified by age group. Measures of association, Cox proportional hazard analyses, and Kaplan-Meier survival curves were performed within the TriNetX Advanced Analytics Platform between racial and ethnic groups for each analysis. From the total sample of 18 152 children, those with hospital-acquired AKI, chronic kidney disease, end-stage kidney failure, or dialysis dependence were excluded, leaving a final cohort of 17 125 children (mean [SD] age, 11.2 [5.2] years; 9424 male [55.3%]). Eligible patients were divided into racial and ethnic groups as follows: non-Hispanic Asian, 1169 children (6.5%); non-Hispanic Black, 4636 children (27.3%); Hispanic, 1786 children (10.2%); and non-Hispanic White, 9534 children (55.9%). Patients were further subdivided into groups aged 0 to 9 years (546 Asian children, 1675 Black children, 689 Hispanic children, and 3340 White children) and 10 to 18 years (623 Asian children, 2961 Black children, 1091 Hispanic children, and 6104 White children). Within 1 year of CA-AKI diagnosis, compared with White children, Black children experienced greater rates of ED visits (hazard ratio [HR], 1.53; 95% CI, 1.40-1.67), ICU admissions (HR, 1.31; 95% CI, 1.16-1.47), mechanical ventilation (HR, 1.33; 95% CI, 1.13-1.56), and all-cause mortality (HR, 1.27; 95% CI, 1.09-1.48), as well as the greatest risk for composite outcomes (HR, 1.43; 95% CI, 1.33-1.53). Hispanic children experienced greater rates of ED visits (HR, 1.40; 95% CI, 1.21-1.62) and the greatest risk of all-cause mortality (HR, 1.66; 95% CI, 1.31-2.09), whereas Asian children experienced greater rates of mechanical ventilation (HR, 1.69; 95% CI, 1.26-2.27), compared with White children. Black and Hispanic children aged 0 to 9 years were at greatest risk of experiencing poor clinical outcomes. Black children had a 11.41% lower survival probability and Hispanic children had a 7.14% lower survival probability compared with White children after an initial ED encounter. Among children with an identified episode of CA-AKI diagnosed in an ED, within 1 year, Black and Hispanic children had a poorer survival probability compared with White children. Future studies are needed to understand these disparities and improve awareness and follow-up after emergency care.

Healthcare utilization following acute myocardial infarction findings from RECORD MI registry

Abstract Background As therapeutic options and epidemiology have evolved rapidly, the contemporary healthcare utilization following acute myocardial infarction (MI) is not well known. Methods All patients admitted with MI between 01/2015 and 12/2021 in the Baylor Scott &amp; White health system were studied. Patient characteristics and outcomes including hospital readmissions, cardiovascular (CV)-related hospital readmissions, emergency department (ED) encounters, and outpatient visits were studied. Results Of 6804 patients, 6556 were discharged alive. Median age was 69 years, 60% were male, and 77% had non-ST elevation MI (NSTEMI); 1172 (22%) had an LVEF &amp;lt;40%, 493 (7.5%) were revascularized within 3 months of discharge, and 1090 (17%) had multivessel disease. The number of unique patients with first hospital readmission within 30-days, 3-months, and 12-months were 844 (13%), 1372 (21%) and 2306 (35%), respectively, with a higher risk in patients with NSTEMI, prior heart failure (HF), new HF, and LVEF &amp;lt;40%. ED visits at 12 months for any cause were 2401 (37%) and for CV cause were 1321 (20%), with a higher risk in patients with prior HF. Patients with at least 1 primary care visit within 12 months of discharge were captured for 4102 (63%), CV specialty visits for 5009 (76%), and non-CV visits for 3860 patients (59%), with similar distribution across subgroups (Table). Conclusions Post-MI patients had a high risk of readmissions, and ED and outpatient visits, especially amongst those with a prior or new HF diagnosis.

Using Atrial Fibrillation Burden Trends and Machine Learning to Predict Near-Term Risk of Cardiovascular Hospitalization.

Atrial fibrillation is associated with an increased risk of cardiovascular hospitalization (CVH), which may be triggered by changes in daily burden. Machine learning of dynamic trends in atrial fibrillation burden, as measured by insertable cardiac monitors (ICMs), may be useful in predicting near-term CVH. Using Optum's deidentified Clinformatics Data Mart Database (2007-2019), linked with the Medtronic CareLink ICM database, we identified patients with >1 days of ICM-detected atrial fibrillation. ICM-detected diagnostic parameters were transformed into simple moving averages over different periods for daily follow-up. A diagnostic trend was defined as the comparison of 2 simple moving averages of different periods for each diagnostic parameter. CVH was defined as any hospital, emergency department, or ambulatory surgical center encounter with a cardiovascular diagnosis-related group or diagnosis code. Machine learning was used to determine which diagnostic trends could best predict patient risk 5 days before CVH. A total of 2616 patients with ICMs met the inclusion criteria (71±11 years; 55% male). Among them, 1998 (76%) had a planned or unplanned CVH over 605 363 days. Machine learning revealed distinct groups: (A) sinus rhythm (reference), (B) below-average burden, (C) above-average burden, and (D) above-average burden with decreasing patient activity. The relative risk was increased in all groups versus the reference (B, 4.49 [95% CI, 3.74-5.40]; C, 8.41 [95% CI, 7.00-10.11]; D, 11.15 [95% CI, 9.10-13.65]), including a 21% increase in CVH detection over prespecified burden thresholds of duration (≥1 hour) and quantity (≥5%). The area under the receiver operating characteristic curve increased from 0.55 when using hourly burden amounts to 0.66 when using burden trends and decreasing patient activity (P<0.001), a 20% increase in predictive power. Trends in atrial fibrillation were strongly associated with near-term CVH, especially above-average burden coupled with low patient activity. This approach could provide actionable information to guide treatment and reduce CVH.

Improving Access to Community-Based Services for Sexual Assault Survivors

ABSTRACT Background Emergency department (ED) encounters are often the only healthcare provider encounter for patients seeking care after a reported sexual assault (SA), making the encounter a crucial opportunity to connect patients to support services in the community. An opportunity existed at an urban Level II trauma center to standardize SA discharge planning. Aims This quality improvement project aimed to improve access to SA support services. Methods The Model for Improvement guided two plan–do–study–act (PDSA) cycles. Implementation included (a) creation of a QR-code-accessible SA resource website, (b) ED standardized patient print and electronic medical record after-visit summaries with follow-up guidelines and the QR code, (c) ED staff education, and (d) a community stakeholder survey to assess facilitators and barriers to support services. Results During the first PDSA cycle, 19 reported SA survivors were seen in the ED (18 adult, one pediatric) and 14 SA resource website visits. During the second PDSA cycle, 13 reported SA survivors (10 adult, three pediatric) were seen in the ED and 29 website visits. Stakeholder survey data revealed barriers to support services were transportation, overloaded support services, and survivor knowledge of existing services. Conclusion The QR code intervention model is a discrete method of improving access to resources and is applicable to other vulnerable populations. The multiagency SA response team will utilize partner survey data to improve access to community resources such as housing and transportation.

Respiratory syncytial virus (RSV) vaccine effectiveness against RSV-associated hospitalisations and emergency department encounters among adults aged 60 years and older in the USA, October, 2023, to March, 2024: a test-negative design analysis

Respiratory syncytial virus vaccines first recommended for use during 2023 were efficacious against lower respiratory tract disease in clinical trials. Limited real-world data regarding respiratory syncytial virus vaccine effectiveness are available. To inform vaccine policy and address gaps in evidence from the clinical trials, we aimed to assess the effectiveness against respiratory syncytial virus-associated hospitalisations and emergency department encounters among adults aged at least 60 years. We conducted a test-negative design analysis in an electronic health records-based network in eight states in the USA, including hospitalisations and emergency department encounters with respiratory syncytial virus-like illness among adults aged at least 60 years who underwent respiratory syncytial virus testing from Oct 1, 2023, to March 31, 2024. Respiratory syncytial virus vaccination status at the time of the encounter was derived from electronic health record documentation, state and city immunisation registries, and, for some sites, medical claims. Vaccine effectiveness was estimated by immunocompromise status, comparing the odds of vaccination among respiratory syncytial virus-positive case patients and respiratory syncytial virus-negative control patients, and adjusting for age, race and ethnicity, sex, calendar day, social vulnerability index, number of underlying non-respiratory medical conditions, presence of respiratory underlying medical conditions, and geographical region. Among 28 271 hospitalisations for respiratory syncytial virus-like illness among adults aged at least 60 years without immunocompromising conditions, vaccine effectiveness was 80% (95% CI 71-85) against respiratory syncytial virus-associated hospitalisations, and vaccine effectiveness was 81% (52-92) against respiratory syncytial virus-associated critical illness (ICU admission or death, or both). Among 8435 hospitalisations for respiratory syncytial virus-like illness among adults with immunocompromising conditions, vaccine effectiveness was 73% (48-85) against associated hospitalisation. Among 36 521 emergency department encounters for respiratory syncytial virus-like illness among adults aged at least 60 years without an immunocompromising condition, vaccine effectiveness was 77% (70-83) against respiratory syncytial virus-associated emergency department encounters. Vaccine effectiveness estimates were similar by age group and product type. Respiratory syncytial virus vaccination was effective in preventing respiratory syncytial virus-associated hospitalisations and emergency department encounters among adults aged at least 60 years in the USA during the 2023-24 respiratory syncytial virus season, which was the first season after respiratory syncytial virus vaccine was approved. The Centers for Disease Control and Prevention.

Mortality Following Childbirth in Ontario: A 20-Year Analysis of Temporal Trends and Causes

ObjectivesMaternal death during or after pregnancy is often preventable and accurate surveillance is key to prevention. We examined the number and causes of maternal death in Ontario over 20 years. MethodsRetrospective cohort study including all hospital livebirths and stillbirths from 2002–2022 in the Canadian Institute for Health Information Discharge Abstracts (for hospitalizations) and National Ambulatory Care System (for emergency department encounters) linked to the Better Outcomes and Registry and Network births. Death was ascertained from childbirth to 365 days thereafter; all deaths were reviewed by at least 3 clinicians. ResultsThere were 485 deaths among 2 764 214 live and stillbirths over 20 years—a maternal mortality ratio (MMR) of 17.5 per 100 000 (95% CI 16.0–19.2). There were 222 (45.8%) early deaths within 42 days of birth (MMR of 8.0 per 100 000; 95% CI 7.0–9.2), and 263 (54.2%) late deaths from 43 to 365 days after birth (MMR 9.5 per 100 000; 95% CI 8.4–10.7). Death was pregnancy-related in 169/485 cases (34.8%). Early death causes were predominantly hemorrhage, infection, preeclampsia, and pulmonary embolism. The top causes of 263 late deaths were cancer, injury, and cardiac arrest, or unknown. ConclusionsMost deaths within 1 year of childbirth are not related to obstetrical factors; however, pregnancy complications factor in early deaths. Causes of early and late deaths differ, but examining late deaths is equally important to identify factors not regularly examined in maternal mortality. As death in early pregnancy or outside hospitals is not reported, mortality is likely higher.

The Impact of Tele-Stewardship on Rural Antibiotic Prescribing Practices

Abstract Background Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. There has been limited research on the effectiveness of tele-stewardship in the outpatient setting. In this study, we address the need for better AS in rural areas by developing, implementing, and evaluating AS interventions using tele-stewardship. Methods We employed bundled outpatient AS implementation strategies in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center (VUMC) using tele-stewardship. The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls on common pediatric infections, communication skills training (DART modules), app-based microlearning modules (QuizTime), and implicit/explicit bias education and (4) quarterly audit and feedback with peer comparison on guideline-concordant antibiotic use. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children &amp;lt;18 years collected during the “baseline” period (Jan-Dec 2022) to the intervention period (Jan-Sept 2023). Two academic urban primary care clinics and one academic urban ED at which the interventions were not implemented were included as “control” sites. The primary outcome is percent of all encounters that result in an antibiotic prescription. Pre- and post-intervention data were analyzed in aggregate (not at the provider-level). Significance was determined via calculating a 95% confidence interval (CI) for the difference of proportions. Results To date, there have been 140,077 PC patient encounters (98,409 baseline and 41,065 intervention) and 94,205 ED encounters (61759 baseline and 32,446 intervention) across all sites. Change from baseline to intervention periods in academic PC sites was 0.9 percentage points (95% CI 0.556 to 1.243; 6.6% baseline, 7.5% intervention) while change in rural intervention sites was -1.05 percentage points (95% CI -0.409 to -1.667; 11.8% baseline, 10.75% intervention; Figure 1a). Only 1 of 3 rural EDs had a decrease in percent of encounters with an antibiotic prescription (Figure 1b). Overall the academic ED showed a 3.1 percentage point increase (95% CI 2.430 to 3.769; 18.0% baseline, 21.1% intervention) while the rural sites showed a 1.0 percentage point increase (95% CI -0.817 to 2.817; 24.2% baseline, 25.2% intervention). Conclusion Interim analysis shows that bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural primary care clinics compared to urban academic control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

Analysis of Dental-related Emergency Department Utilization in Michigan

Objective: Emergency departments (ED) are critical to the United States healthcare system. However, they are known to be inefficient environments to deliver definitive care including management of dental emergencies. ED’s may also serve as an inadvertent, but important, stop gap for individuals who lack dental coverage. The nation’s healthcare system continues to struggle with inadequate resources to provide dental care for vulnerable patients who disproportionately suffer from dental-related conditions. Method: This study is an analysis on dental-related ED utilization in the state of Michigan. The authors collaborated with the Michigan Health &amp; Hospital Association who provided data from the Michigan Inpatient and Outpatient Database for dental-related hospital emergency department (ED) visits in Michigan hospitals during 2018-2019. University of Michigan Medical School’s committee on human subjects’ research reviewed the protocol and provided IRB exemption (HUM00192629). Results: State funded Medicaid (33%) and federally funded Medicare (33%) were the most common payer types for patients with dental-related conditions who reported to Michigan ED’s from 2018 to 2019. Charges per ED encounter was the highest for Medicare, $2,900-$3,200, and lowest for other payers, $1,300-$1,500. Charges for ED-inpatient per encounter were the highest for Medicare ($22,000-$24,000). The age range for which patients most frequently presented to the emergency department (ED) was 25-64. However, expenses per encounter for patients 65 and older were roughly two to three times higher than for patients in other age ranges. Conclusion: The study revealed a disproportionately higher percentage of patients who identified as Black presented to Michigan emergency departments (30%) with a dental-related emergency.

Antibiotic Appropriateness for Urinary Tract Infections in Children.

We examined local prescribing patterns across the entire treatment course for children treated for uncomplicated urinary tract infection (UTI) to determine opportunities for antibiotic stewardship initiatives. We conducted a retrospective review of emergency department and inpatient encounters for febrile and afebrile UTI in a children's hospital from 2021 to 2022. An antibiotic spectrum ranking was established, and providers' choices were assessed for appropriateness on the basis of the individuals' urine culture (UCx). Groups were stratified by fever presence and compared using χ2, Fisher's exact, and Mann-Whitney U tests. Of 172 encounters (83% emergency department), 99 (58%) had a positive UCx. Eighty (80%) grew Escherichia coli, with 67 (84%) being susceptible to cefazolin (minimum inhibitory concentration ≤16 mg/L). There were 229 antibiotic regimens and 39 (17%) were appropriate. Inappropriate antibiotic choices included unnecessary use of broad-spectrum antibiotics and misdiagnosed UTI. Grouping by encounter, at least 1 dose of a third cephalosporin was given in 51% of encounters, and 80% of these received it unnecessarily because of UTI misdiagnosis or suitability of a narrower-spectrum antibiotic. The median prescribed antibiotic duration was 7 days (interquartile range 7-10). Of 73 encounters with UCx growing mixed flora or a nonuropathogen, only 29 (40%) had antibiotics discontinued. Confirmed UTI was associated with fever and nitrite positivity. Our study revealed high prevalence of inappropriate antibiotics, particularly unnecessary prescribing of third cephalosporin, prescriptions not supported by laboratory data, and prolonged treatment courses. Our results identify factors that can be used to support UTI treatment pathways and ensure antibiotic stewardship.

Diverticulitis evaluation and management among United States emergency departments over an eight-year period

IntroductionDiverticulitis is a common reason for presentation to the Emergency Department (ED). However, as imaging options, risk stratification tools, and antibiotic options have expanded, there is a need for current data on the changes in incidence, computed tomography (CT) performance, antibiotic usage, and disposition over time. MethodsThis was a cross-sectional study of ED patients with a diagnosis of diverticulitis from 1/1/2016 to 12/31/2023. Using the Epic Cosmos database, all ED visits for acute diverticulitis were identified using ICD-10 codes. Outcomes included total ED presentations for diverticulitis, admission rates, CTs performed, outpatient antibiotic prescriptions, and antibiotics administered in the ED for admitted patients. ResultsThere were 186,138,130 total ED encounters, with diverticulitis representing 927,326 (0.50 %). The rate of diverticulitis diagnosis increased from 0.40 % to 0.56 % over time. The admission rate declined over time from 33.6 % to 27.7 %, while the CT rate rose from 83.0 % to 92.6 %. Among those discharged, 90.4 % received an antibiotic, which remained consistent over time. Metronidazole (55.1 %) and ciprofloxacin (40.8 %) were the most commonly prescribed antibiotics, followed by amoxicillin-clavulanate (36.1 %). Among those admitted, most received either metronidazole (62.0 %), a fluoroquinolone (40.4 %), a third-generation cephalosporin (18.9 %), or a penicillin-based agent (38.1 %). Among both discharged and admitted patients, there was a marked shift to penicillin-based agents as the primary antibiotic regimen. ConclusionDiverticulitis remains a common ED presentation, with a gradually rising incidence over time. Admission rates have decreased, while CT imaging has become more common. Most patients receive antibiotics, though the specific antibiotic has shifted in favor of penicillin-based agents. These findings can provide key benchmarking data and inform future initiatives to guide imaging and antibiotic use.

221 Opportunities for Antibiotic Stewardship for Pediatric Urinary Tract Infection for Outpatient Emergency Department and Urgent Care Encounters

221 Opportunities for Antibiotic Stewardship for Pediatric Urinary Tract Infection for Outpatient Emergency Department and Urgent Care Encounters

Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era.

To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018). We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization. Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05). We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.

Development and Evaluation of Pediatric Acute Care Hospital Referral Regions in Eight States

To develop a set of pediatric acute care hospital referral regions for use in studying pediatric acute care delivery, and test their utility relative to other regional systems. We used state-level administrative databases capturing all pediatric acute care in eight states to construct novel referral regions. We first constructed pediatric hospital service areas (PHSAs) based on 5,837,464 pediatric emergency department encounters. We then aggregated these PHSAs to pediatric hospital referral regions (PHRRs) based on 344,440 pediatric hospitalizations. Finally, we used three measures of spatial accuracy (localization index, market share index, and net patient flow) to compare this novel region system with the Dartmouth Atlas, designed originally to study adult specialty care, and the Pittsburgh Atlas, designed originally to study adult acute care. The development procedure resulted in 717 novel PHSAs, which were then aggregated to 55 PHRRs across the included states. Relative to HRRs in the Dartmouth and Pittsburgh Atlases, PHRRs were fewer in number and larger in area and population. PHRRs more accurately captured patterns of pediatric hospitalizations, (eg, mean localization index: 69.1 out of 100, compared with a mean of 58.1 for the Dartmouth Atlas and 62.4 for the Pittsburgh Atlas). The use of regional definitions designed specifically to study pediatric acute care better captures contemporary pediatric acute care delivery than the use of existing regional definitions. Future work should extend these definitions to all US states to enable national analyses of pediatric acute care delivery.

Epidemiology of heart failure presentations to United States emergency departments from 2016 to 2023

IntroductionHeart failure (HF) is a common condition prompting presentation to the Emergency Department (ED) and is associated with significant morbidity and mortality. However, there is limited recent large-scale, robust data available on the admission rates, evaluation, and treatment of HF in the ED setting. MethodsThis was a cross-sectional study of ED presentations for HF from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits with ICD-10 codes corresponding to acute HF were included. We excluded congenital heart disease and isolated right-sided HF. Outcomes included percentage of total ED visits, admission rates, troponin, B-type natriuretic peptide (BNP), chest radiography, and diuretic and nitroglycerin medication administration. Subgroup analyses of medications were performed by medication and route of administration (transdermal, sublingual/oral, and intravenous). ResultsOut of 190,694,752 ED encounters, 2,626,011 (1.4 %) visits were due to acute HF. Of these, 1,897,369 (72.3 %) were admitted to the hospital. The majority of patients had a troponin (90.3 %), BNP (91.1 %), and chest radiograph (89.5 %) ordered. 82.5 % received intravenous diuresis, while 46.2 % received oral diuresis. The most common diuretic was furosemide (78.4 % intravenous, 32.5 % oral), followed by bumetanide (9.5 % intravenous, 7.1 % oral), and torsemide (0 % intravenous, 8.1 % oral). Nitroglycerin was given in 26.0 %, with the most common route being sublingual/oral (16.6 %), followed by transdermal (9.2 %) and intravenous (3.5 %). ConclusionHF represents a common reason for ED presentation, with the majority of patients being admitted. All patients received diuresis in the ED, with the majority receiving intravenous diuresis with furosemide. Approximately one-quarter received nitroglycerin with the sublingual/oral route being most common. These findings can help inform health policy initiatives, including admission decisions and evidence-based medication administration.