Emergency Department Evaluation Research Articles

Emergency Department Evaluation of Young Infants With Head Injury.

We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children. Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old. We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%). The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population.

Socioeconomic and racial disparities in revisits, indication, and readmission or reoperation in pediatric tonsillectomy

IntroductionPediatric tonsillectomy is a frequent otolaryngologic procedure. This study aimed to characterize disparities in post-tonsillectomy revisits, including emergency department evaluation, readmission, or reoperation as well as indication for revisit. MethodsCases of inpatient and ambulatory pediatric tonsillectomy in New York and Florida in 2016 constituted the analytic sample. Patients were extracted from the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) and linked to the SID and State Emergency Department Database (SEDD) and SASD. Outcomes include 3 types of revisits within 30 days: ED visits, hospital readmissions, and reoperation. Indication for revisit was also analyzed. Multivariable analysis determined the association of each outcome with gender, age, race/ethnicity, primary payer, urbanicity, and zip code median household income quartile. The Holm Bonferroni test was used to correct for multiple hypothesis testing. Results15,264 pediatric tonsillectomies were included. The revisit rate was 6.77% (N = 1,034, 49.1% female; 6 years median age [interquartile range: 5]). The 30-day ED revisit rate was 4.85%, readmission rate was 1.27%, and reoperation rate was 0.65%. On multivariate analysis, Latinx patients (OR = 3.042, 95% CI = 1.393–6.803) and those who identify as other race/ethnicity (OR = 6.116, 95% CI = 1.989–19.245) have greater odds of requiring inpatient care for indications including pain, dehydration, nausea, and vomiting compared to white patients. No significant differences in tier of care for the management of post-tonsillectomy hemorrhage were identified. ConclusionDisparities in pediatric post-tonsillectomy ED presentation, readmission and reoperation demonstrate opportunities to improve patient safety and equity.

Unrecognized Focal Nonmotor Seizures in Adolescents Presenting to Emergency Departments.

Many adolescents with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history-taking is essential to prompt diagnosis and treatment. In this study, we investigated ED recognition of motor vs nonmotor seizures and its effect on management and treatment of focal epilepsy in adolescents. This was a retrospective analysis of enrollment data from the Human Epilepsy Project (HEP), an international multi-institutional study that collected data from 34 sites between 2012 and 2017. Participants were 12 years or older, neurotypical, and within 4 months of treatment initiation for focal epilepsy. We used HEP enrollment medical records to review participants' initial diagnosis and management. A total of 83 adolescents were enrolled between 12 and 18 years. Fifty-eight (70%) presented to an ED before diagnosis of epilepsy. Although most ED presentations were for motor seizures (n = 52; 90%), many patients had a history of nonmotor seizures (20/52 or 38%). Adolescents with initial nonmotor seizures were less likely to present to EDs (26/44 or 59% vs 32/39 or 82%, p = 0.02), and nonmotor seizures were less likely to be correctly identified (2/6 or 33% vs 42/52 or 81%, p = 0.008). A history of initial nonmotor seizures was not recognized in any adolescent who presented for a first-lifetime motor seizure. As a result, initiation of treatment and admission from the ED was not more likely for these adolescents who met the definition of epilepsy compared with those with no seizure history. This lack of nonmotor seizure history recognition in the ED was greater than that observed in the adult group (0% vs 23%, p = 0.03) and occurred in both pediatric and nonpediatric ED settings. Our study supports growing evidence that nonmotor seizures are often undiagnosed, with many individuals coming to attention only after conversion to motor seizures. We found this treatment gap is exacerbated in the adolescent population. Our study highlights a critical need for physicians to inquire about the symptoms of nonmotor seizures, even when the presenting seizure is motor. Future interventions should focus on improving nonmotor seizure recognition for this population in EDs.

Modern Trends in Nasal Bone Fractures and the Effect of Social Distancing

Objectives: To assess differences in demographics, incidence, and cause of nasal bone fractures (NBFs) between pre–coronavirus disease 2019 (COVID-19) and COVID-19 eras. Methods: The National Electronic Injury Surveillance System was queried for adult NBF. Two sample t tests and Wald χ2 tests were used to identify changes across the 2012 to 2019 period and 2020 to 2021 period (age, sex, race, location, disposition, and product). Results: There was a total of 523,259 (95% CI: 445,082–601,436) emergency department (ED)–treated adult NBFs in the United States. There was a greater incidence of NBF during COVID-19 (61,621 annual cases; 95% CI: 61,572–61,669) compared with pre–COVID-19 (50,773 annual cases; 95% CI: 50,195–51,351; P &lt; 0.01). Fewer patients with NBF were discharged after ED evaluation during COVID-19 (79.46%; 95% CI: 74.45%–83.70%) compared with before (84.41%; 95% CI: 82.36%–86.28%; P = 0.049, t test). During COVID-19, there was a decrease in sport-associated NBFs, such as basketball [2.36% (95% CI: 1.71%–3.27%) versus 5.21% (95% CI: 4.20%–6.45%), P &lt; 0.01] and baseball [1.18% (95% CI: 0.82%–1.69%) versus 2.22% (95% CI: 1.80%–2.74%), P&lt;0.01], but an increase in fall (66.34% versus 75.02%), alcohol (7.04% versus 12.89%), and drug-associated (0.47% versus 5.70%) NBFs (all P &lt; 0.001). Conclusion: A greater incidence of NBFs has been observed since the start of the COVID-19 pandemic without significant changes in sex or race. Nasal bone fractures during COVID-19 were less likely to be related to sports or discharged from the ED and more likely to be associated with drugs and alcohol. Changes in sociobehavioral patterns during these unprecedented times may account for post–COVID-19 NBF etiologic drift. Level of Evidence: Level II—retrospective cohort study.

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

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

Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland

ObjectiveRecovery from acute wheeze and asthma attacks should be supported with safety netting, including treatment advice. We evaluated emergency department (ED) discharge practices for acute childhood wheeze/asthma attacks to describe...

Emergency Department Visits Before Cancer Diagnosis Among Women at Mayo Clinic

ObjectiveTo determine associations of incident cancer diagnoses in women with recent emergency department (ED) care. Patients and MethodsA retrospective cohort study analyzing biological females aged 18 years and older, who were diagnosed with an incident primary cancer (12 cancer types studied) from January 1, 2015, to December 31, 2021, from electronic health records. The primary outcome was a cancer diagnosis within 6 months of a preceding ED visit. Secondary outcomes included patient factors associated with a preceding ED visit. ResultsOf 25,736 patients (median age of 62 years, range 18-101) diagnosed with an incident primary cancer, 1938 (7.5%) had an ED visit ≤6 months before a diagnosis. The ED-associated cancer cases were highest in lung cancer (n=514, 14.7%) followed by acute lymphoblastic leukemia (n=22, 13.3%). Patient factors increasing the likelihood of ED evaluation before diagnosis included 18-50 years of age (OR=1.32; 95% CI, 1.09-1.61), Elixhauser score (measure of comorbidities) >4 (OR=17.90; 95% CI, 14.21-22.76), use of Medicaid or other government insurance (OR=2.10; 95% CI, 1.63-2.69), residence within the institutional catchment areas (OR=3.18; 95% CI, 2.78-3.66), non-Hispanic Black race/ethnicity (OR=1.41; 95% CI, 1.04-1.88), and established primary care provider at Mayo Clinic (OR=1.45; 95% CI, 1.28-1.65). The ED visits were more likely in those who died within 6 months of diagnosis (n=327, 37.8%) than those who did not die (n=1611, 6.5%). ConclusionPatient characteristics identified in this study offer opportunities to provide cancer risk assessment and health navigation, particularly among individuals with comorbidities and limited health care access.

An all-inclusive model for predicting invasive bacterial infection in febrile infants age 7-60 days.

Invasive bacterial infections (IBIs) in febrile infants are rare but potentially devastating. We aimed to derive and validate a predictive model for IBI among febrile infants age 7-60 days. Data were abstracted retrospectively from electronic records of 37 emergency departments (EDs) for infants with a measured temperature >=100.4 F who underwent an ED evaluation with blood and urine cultures. Models to predict IBI were developed and validated respectively using a random 80/20 dataset split, including 10-fold cross-validation. We used precision recall curves as the classification metric. Of 4411 eligible infants with a mean age of 37 days, 29% had characteristics that would likely have excluded them from existing risk stratification protocols. There were 196 patients with IBI (4.4%), including 43 (1.0%) with bacterial meningitis. Analytic approaches varied in performance characteristics (precision recall range 0.04-0.29, area under the curve range 0.5-0.84), with the XGBoost model demonstrating the best performance (0.29, 0.84). The five most important variables were serum white blood count, maximum temperature, absolute neutrophil count, absolute band count, and age in days. A machine learning model (XGBoost) demonstrated the best performance in predicting a rare outcome among febrile infants, including those excluded from existing algorithms. Several models for the risk stratification of febrile infants have been developed. There is a need for a preferred comprehensive model free from limitations and algorithm exclusions that accurately predicts IBIs. This is the first study to derive an all-inclusive predictive model for febrile infants aged 7-60 days in a community ED sample with IBI as a primary outcome. This machine learning model demonstrates potential for clinical utility in predicting IBI.

Clinical Trials Studying Suicide Risk Reduction: Who is Excluded From Participation

Objective The use of exclusion criteria in clinical trials can cause research participants to differ markedly from clinical populations, which negatively impacts generalizability of results. This study identifies and quantifies common and recurring exclusion criteria in clinical trials studying suicide risk reduction, and estimates their impact on eligibility among a clinical sample of adults in an emergency department with high suicide risk. Method Recent trials were identified by searching PubMed (terms suicide, efficacy, effectiveness, limited to clinical trials in prior 5 years). Common exclusion criteria were identified using Qualitative Content Analysis. A retrospective chart review examined a one-month sample of all adults receiving psychiatric evaluation in a large urban academic emergency department. Results The search yielded 27 unique clinical trials studying suicide risk reduction as a primary or secondary outcome. After research fundamentals (e.g. informed consent, language fluency), the most common exclusion criteria involved psychosis (77.8%), cognitive problems (66.7%), and substance use (63.0%). In the clinical sample of adults with high suicide risk (N = 232), psychosis exclusions would exclude 53.0% of patients and substance use exclusions would exclude 67.2% of patients. Overall, 5.6% of emergency psychiatry patients would be eligible for clinical trials that use common exclusion criteria. Conclusions Recent clinical trials studying suicide risk reduction have low generalizability to emergency psychiatry patients with high suicide risk. Trials enrolling persons with psychosis and substance use in particular are needed to improve generalizability to this clinical population.

Comparing Doppler Ultrasonography and Computerized Tomography Angiography in Emergency Department Evaluation of Earthquake-Related Crush Injuries: A Case Series Analysis.

This case series aims to provide a comprehensive description of the utilization of doppler ultrasonography (USG) and computerized tomography angiography (CTA) in evaluating patients with earthquake-induced crush injuries in the emergency department (ED). This retrospective case series was conducted on 11 patients who presented with crush injuries following a seismic event. These patients underwent initial assessment using doppler USG, with CTA performed when deemed necessary. Clinical outcomes and diagnostic findings were systematically reviewed. A cohort of 11 earthquake-related crush injury patients (six females, five males; age 3-59 years), predominantly with lower extremity injuries, with entrapped durations that ranged from 12 to 128 hours. Transport centers received patients from both affected regions and nearby provinces. Initial X-rays identified fractures in two cases. Doppler USG and subsequent CTA were employed for vascular evaluation, with CTA confirming doppler USG findings. Of the 11 patients, five exhibited abnormal doppler USG findings. Four patients required dialysis and four underwent amputation surgery. Fasciotomy and debridement procedures were performed in five and seven patients, respectively. Three patients received hyperbaric oxygen therapy (HBOT). Doppler USG emerged as a dependable tool for assessing vascular injuries in earthquake-related crush injuries, offering an effective alternative to CTA without the associated contrast agent risks. These findings underscore the need for further research to establish definitive imaging guidelines in these challenging clinical scenarios.

Pediatric Asthma Exacerbations: 14-Day Emergency Department Return Visit Risk Factors

BackgroundAsthma, the most common chronic disease of childhood, can affect a child's physical and mental health and social and emotional development. ObjectiveThe aim of this study was to identify factors associated with emergency department (ED) return visits for asthma exacerbations within 14 days of an initial visit. MethodsThis was a retrospective review from Cerner Real-World Data for patients aged from 5 to 18 years and seen at an ED for an asthma exacerbation and discharged home at the index ED visit. Asthma visits were defined as encounters in which a patient was diagnosed with asthma and a beta agonist, anticholinergic, or systemic steroid was ordered or prescribed at that encounter. Return visits were ED visits for asthma within 14 days of an index ED visit. Data, including demographic characteristics, ED evaluation and treatment, health care utilization, and medical history, were collected. Data were analyzed via logistic regression mixed effects model. ResultsA total of 80,434 index visits and 17,443 return visits met inclusion criteria. Prior ED return visits in the past year were associated with increased odds of a return visit (odds ratio [OR] 2.12; 95% CI 2.07–2.16). History of pneumonia, a concomitant diagnosis of pneumonia, and fever were associated with increased odds of a return visit (OR 1.19; 95% CI 1.10–1.29; OR 1.15; 95% CI 1.04–1.28; OR 1.20; 95% CI 1.11–1.30, respectively). ConclusionsSeveral variables seem to be associated with statistically significant increased odds of ED return visits. These findings indicate a potentially identifiable population of at-risk patients who may benefit from additional evaluation, planning, or education prior to discharge.

Prospective Bidirectional Relationship Between Sleep Duration and Posttraumatic Stress Disorder Symptoms After Suspected Acute Coronary Syndrome.

Sleep disturbance is a "hallmark" symptom of posttraumatic stress disorder (PTSD). Poor sleep (including short sleep) after combat-related trauma can also predict subsequent PTSD. Less is known about the association between sleep duration and PTSD symptoms when PTSD is induced by acute coronary syndrome (ACS). We examined the bidirectional relationship between sleep duration and PTSD symptoms over the year after hospital evaluation for ACS. Participants were enrolled in this observational study after emergency department evaluation for ACS. Sleep duration ("During the past month, how many hours of actual sleep did you get at night?") and cardiac event or hospitalization-induced PTSD symptoms (PTSD Checklist) were assessed at 1, 6, and 12 months after hospital discharge. Cross-lagged path analysis was used to model the effects of sleep duration and PTSD symptoms on each other. Covariates included age, sex, race/ethnicity, cardiac severity, baseline depression symptoms, and early acute stress disorder symptoms. The sample included 1145 participants; 16% screened positive for probable PTSD (PTSD Checklist score ≥33). Mean sleep duration across time points was 6.1 hours. Higher PTSD symptoms predicted shorter sleep duration at the next time point (i.e., 1-6 and 6-12 months; B = -0.14 hours/10-point difference, SE = 0.03, p < .001). Shorter sleep duration was associated with higher PTSD symptoms at the next time point (B = -0.25 points/hour, SE = 0.12, p = .04). Short sleep duration and PTSD symptoms are mutually reinforcing across the first year after ACS evaluation. Findings suggest that sleep, PTSD symptoms, and their relationship should be considered in the post-ACS period.

Validity of Computer-interpreted "Normal" and "Otherwise Normal" ECG in Emergency Department Triage Patients.

Chest pain is the second most common chief complaint for patients undergoing evaluation in emergency departments (ED) in the United States. The American Heart Association recommends immediate physician interpretation of all electrocardiograms (ECG) performed for adults with chest pain within 10 minutes to evaluate for the finding of ST-elevation myocardial infarction (STEMI). The ECG machines provide computerized interpretation of each ECG, potentially obviating the need for immediate physician analysis; however, the reliability of computer-interpreted findings of "normal" or "otherwise normal" ECG to rule out STEMI requiring immediate intervention in the ED is unknown. We performed a prospective cohort analysis of 2,275 ECGs performed in triage in the adult ED of a single academic medical center, comparing the computerized interpretations of "normal" and "otherwise normal" ECGs to those of attending cardiologists. ECGs were obtained with a GE MAC 5500 machine and interpreted using Marquette 12SL. In our study population, a triage ECG with a computerized interpretation of "normal" or "otherwise normal" ECG had a negative predictive value of 100% for STEMI (one-sided, lower 97.5% confidence interval 99.6%). None of the studied patients with these ECG interpretations had a final diagnosis of STEMI, acute coronary syndrome, or other diagnosis requiring emergent cardiac catheterization. In our study population, ECG machine interpretations of "normal" or "otherwise normal" ECG excluded findings of STEMI. The ECGs with these computerized interpretations could safely wait for physician interpretation until the time of patient evaluation without delaying an acute STEMI diagnosis.

Emergency Department Recognition of Delirium: Quality Improvement Towards a Geriatric-Friendly ED

Introduction: Delirium is a common yet often undetected condition in the elderly, particularly in the Emergency Department (ED). Its subtle presentation makes timely recognition challenging. Literature shows up to 10% of older patients presenting to the Emergency Department will have Delirium, but typically only 30% of these cases are identified in the Emergency Department. Aims/Objectives: To implement quality improvement measures for early recognition of delirium in geriatric patients aged 65+ in a single center ED. Specific objectives include staff training on delirium identification, enhancing screening protocols, and implementing interventions to address delirium promptly. Materials/Methods: ED staff providers underwent systematic training to optimize integration of Delirium Triage Screening (DTS) and Confusion Assessment Method (CAM), customized to the UAE patient population, into the geriatric ED workflow. A multidisciplinary team consisting of Geriatrics, Internal Medicine, ED Staff Physicians &amp; Nurses established Quality Improvement Projects as part of a transition to a geriatric-friendly ED. Patients diagnosed with Delirium were retrospectively studied across 3 months to assess for use of DTS and CAM in ED evaluation. Results: The collected data demonstrates a small percentage of patients with a diagnosis of Delirium. Given that the average frequency of Delirium tends to be around 10% in geriatric patients presenting to the ED, the presence of Delirium at our ED at 0.97% may represent a possible under-diagnosis of the condition. Documentation for both DTS and CAM was suboptimal, well below the target of at least 90%. While the policy prepared was comprehensive, communication of the recognition and assessment pathways could be improved. Discussion: Following suboptimal initial results, dedicated internal departmental learning lectures were organized that focused specifically on the DTS and CAM assessments, with ample time for questions and answers with discussion to best understand and integrate these assessments into our ED workflow. Conclusion: An improved understanding of Delirium, followed by an enhanced integration of validated screening tools will invariably improve ED recognition of Delirium, thereby improving patient-oriented outcomes for elderly individuals presenting to the ED.

Changes in Clinical Management Following 14-Day Ambulatory ECG Monitoring Following Emergency Department Evaluation for Unexplained Syncope

Changes in Clinical Management Following 14-Day Ambulatory ECG Monitoring Following Emergency Department Evaluation for Unexplained Syncope

Plasma soluble suppression of tumorigenesis 2 measured in the emergency department for diagnosis and outcome prediction of sepsis: A single-center prospective study

Background and aimsThe diagnostic and prognostic performance of soluble Suppression of Tumorigenicity 2 (sST2) in suspected septic patients presenting to the Emergency Department (ED) is largely unknown. Materials and methodsPatients were included in this prospective study if there was high suspicion of sepsis. The plasma level of sST2 was measured during initial ED evaluation. Outcomes were the evaluation of (1) sST2 diagnostic performance (alone and in combination with procalcitonin [PCT]), and (2) sST2 ability to predict 30-day and 90-day all-cause mortality. ResultsAmong 569 patients included, 481 (84.5 %) had sepsis or septic shock. Plasma sST2 levels were more elevated in septic patients (159 [71–331] vs 50 [31–103] ng/mL, P < 0.001). The AUC of sST2 for sepsis diagnosis was lower than the AUC of PCT (0.76 vs 0.85, P = 0.03). The best cut-off for sST2 was 61.7 ng/mL, with a sensitivity of 79.9 % and a specificity of 70.6 %. sST2 was able to correctly reclassify septic patients with PCT <0.5 (NRI 28.9 % [P = 0.02]). sST2 level was an independent predictor of 30-day mortality in a model including clinical variables (aHR 2.03 [1.24–3.33], C-index 0.69). ConclusionsST2 could be a useful adjunct in diagnosing sepsis and in all-cause mortality prediction.

Emergency department evaluation of transplanted children with COVID-19

BackgroundChildren usually have an asymptomatic or mild course of SARS-CoV-2 infection, studies in immunocompromised patients have shown a different evolution. The aim of this study was to describe the clinical, laboratory, and radiologic manifestations of pediatric solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) patients testing positive for SARS-CoV-2. MethodsA multicenter retrospective, observational descriptive study was conducted in 3 tertiary hospitals in Madrid (Spain) between March 2020 and December 2022. Consecutive patients aged 0–18 attending the corresponding pediatric emergency departments with a positive result in the real-time polymerase chain reaction test or antigenic test to detect SARS-CoV-2 in the nasopharyngeal sample were included. ResultsA total of 31 children were included in the study. Sixteen (51.6%) were patients with HSCT and 15 (48.3) were patients with SOT. The median time from transplantation to COVID-19 was 1.2 years (IQR:0.5–5.1). The SOT cohort included liver (n = 4, 12.9%), kidney (n = 4, 12.9%), heart (n = 3, 9.7%), multivisceral (n = 3, 9.7%), and lung (n = 1, 3.2%). Of the 31 patients, only one was asymptomatic. The most common symptom on presentation was fever (76.7%). Abnormalities were seen on chest X-ray in 8 (66.6%) of the 12 patients. There was no significant difference in clinical manifestations, lymphopenia and radiological findings regardless of the type of transplantation or immunosuppression status. Thirteen patients (41.9%) were hospitalized. There were no patient deaths. ConclusionsIn our study, we found that the clinical course and outcome of SOT and HSCT pediatric patients with COVID-19 were generally favorable.

Evaluation of a STAT MRI Protocol for Emergent Ophthalmology Patients.

Evaluating patients with potentially sight-threatening conditions frequently involves urgent neuroimaging, and some providers recommend expediting emergency department (ED) evaluation. However, several factors may limit the practicality of ED evaluation. This pilot study assessed the feasibility and safety of a STAT magnetic resonance imaging (MRI) protocol, designed to facilitate outpatient MRI within 48 hours of referral, compared with ED evaluation for patients with optic disc edema. A retrospective chart review was performed. Demographics, clinical data, and baseline ophthalmic measures were compared between patients in STAT and ED groups using the t test or Fisher exact test. Multivariate analyses compared changes in visual acuity (VA), visual field mean deviation (VF MD), retinal nerve fiber layer thickness, and edema grade between presentation and follow-up using a mixed-effects model adjusting for age, sex, and baseline measures. A total of 70 patients met the study criteria-24 (34.3%) in the STAT MRI cohort and 46 (65.7%) in the ED cohort. Demographic variables were similar between groups. Patients referred to the ED had worse VA ( P < 0.001), larger VF MD ( P < 0.001), and higher edema grade ( P = 0.002) at presentation. Four patients in the ED group and none in the STAT group were found to have space-occupying lesions. Multivariate analyses showed that follow-up measures were significantly associated with their baseline values (all P < 0.001) but not with referral protocol (all P > 0.099). The STAT MRI protocol was associated with lower average patient charges and hospital costs. The STAT MRI protocol did not result in inferior visual outcomes or delay in life-threatening diagnoses. Urgent outpatient evaluation, rather than ED referral, seems safe for some patients with optic disc edema. These findings support continued utilization of the protocol and ongoing improvement efforts.

Prior Diagnosis of Opioid Related Disorder is Associated with Higher Medical Resource Utilization Following Primary Hip Arthroscopy: A National Database Study

To compare adverse events, medical resource utilization, prescribing patterns, and revision surgery rates of patients with opioid-related disorders (ORDs) undergoing primary hip arthroscopy against a propensity-matched group with no opioid-related disorders (NORDs). The TriNetX database was queried between January 2015 and December 2020 using International Classification of Diseases, 10th Revision and Current Procedural Terminology codes to identify patients undergoing primary hip arthroscopy between ages 18 and 70 years. The ORD cohort was propensity matched in a 1:1 ratio to NORD patients based on age, sex, alcohol-related disorders, heart disease, hypertension, metabolic disorders, anxiety disorders, major depressive disorder, diabetes mellitus, and antidepressant prescriptions. Postoperative rates of adverse events and medical resources were compared within 90 days of procedure, prescriptions were compared within 1 year, and revision surgery was compared within 2 years. A total of 809 ORD patients were propensity matched in a 1:1 ratio to NORD patients. Postoperative adverse events were similar between groups (P= .693). Rates of revision arthroscopy were also similar for both ORD (9.3%) and NORD (8.0%) cohorts (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.83-1.66; P= .377). ORD patients received care from the emergency department, inpatient admission, outpatient visit, and physical therapy evaluations at higher rates. The ORD cohort received a greater amount of new opioid (OR, 2.66; 95% CI, 2.17-3.26; P < .0001) and antidepressant prescriptions (OR, 1.58; 95% CI, 1.26-1.97; P < .0001) compared to NORD patients within 1 year of surgery. ORD patients demonstrated similar rates of adverse events and revision surgery when compared to a propensity-matched group of NORD patients undergoing primary hip arthroscopy. However, ORD patients experienced increased rates of emergency department visits and hospitalizations and were prescribed higher rates of opioid and antidepressant prescriptions. Level III, cohort study.

Emergency Department Utilization for Heavy Menstrual Bleeding (2016-2020): An Opportunity to Improve Care

Introduction: Heavy Menstrual Bleeding (HMB) is one of the most common indications for ambulatory gynecological visits amongst reproductive aged women. It can have significant physical, social, emotional, and economic impact. Two thirds of women who report HMB develop anemia. While the outpatient setting may represent the optimal setting for management of this condition, it is known that many patients are treated in the emergency room or inpatient setting. We sought to evaluate Emergency Department (ED) utilization and the associated health care charges of patients who present to the ED with HMB. We hypothesized that marginalized groups are more likely to use the ED for HMB and are more likely to be admitted for this condition. Methods: The Nationwide Emergency Department Sample (NEDS) Database of the Health Cost and Utilization Project (HCUP, Rockville, MD) was queried for all visits with primary ICD-10 diagnosis codes of N92.0 (Excessive and Frequent Menstruation with Regular Cycle) or N92.4 (Excessive bleeding in the premenopausal period) among females 21-50 years of age. Variables assessed included age, hospital type, medical insurance, household income quartile, visit charges, disposition, and race. Race data were only available for 2019 and 2020. Z-test and Chi-square analyses were performed to compare counts and proportions across groups and years. All analyses were performed using SAS 9.4 (Cary, NC). Results: Between 2016 and 2020, 195,499 emergency room visits with a primary diagnosis of HMB were identified out of 164,441,890 total ED visits (0.12% of visits). The patient mean (SD) age was 33.7 (0.1) years. Total ED visits per year for HMB declined from 42,462 in 2016 to 33,718 in 2020. Self-pay represents a disproportionately high share of admissions. Approximately 6% of patients who presented to the ED with HMB were admitted which was stable from 2016-2020. Patients age 21-25 years represented the highest proportion of ED visits for HMB with 21.5% versus 12.2% among those ages 46-50 years. However, patients age 46-50 years accounted for 24.6% of admissions versus 6.3% of admissions for those aged 21-25 years. Patients 46-50 years had the highest admission rate (13.2%) versus 1.9% for ages 21-25 years. HMB related charges were over $150,000,000 per year, with a median charge per visit of over $3,000. For the two years for which race data were available, White women (WW) represented 41.2% of HMB visits versus 50.6% of all other diagnoses visits; Black women (BW) represented 28.6% of HMB ED visits versus 25.6% of all other diagnoses, and Hispanic women (HW) 22.1% of HMB ED visits versus 17.2% of all other diagnoses. Of the patients that were admitted for HMB, 31% were White versus 51% of all other diagnoses admissions, 33% were Black compared to 23% of all other diagnoses admissions, and 28% were Hispanic versus 18% of all other diagnoses admissions. Admission rates were higher for Black/Hispanic/Asian-Pacific Islanders (7.6%, 8.2%, 9.1%) vs. WW (4.9%). Percentage of ED visits for HMB for BW and HW were 29% and 22% respectively which compared to 25.6% and 17.2% of visits for all other diagnoses. Conclusion: ED visits with HMB as a primary diagnosis represent a small percent of visits overall and are decreasing. However, Black and Hispanic patients make up a disproportionate percentage of HMB patients. In addition, there is an inverse relationship with respect to age between ED visits and admissions. Younger adults ages 21-25 years make up the highest percentage of ED visits by age, but they are the least likely to be admitted with an admission rate of 1.9% suggesting an opportunity to better leverage an outpatient visit setting for this demographic. This analysis serves as a first step to understand ED utilization for HMB, and suggest potential disparities in ED utilization and/or admissions for HMB by age and race. Given the overall low admission rate, there may be an opportunity to improve outpatient services for HMB in younger women and in Black and Hispanic women.