Emergency Department Outcomes Research Articles

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.

Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes

Objectives Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. Methods This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). Results Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. Conclusions In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Abstract 3823: Clinical outcomes of uveal melanoma patients in the emergency department

Abstract Purpose: Uveal melanoma is a rare ocular malignancy that has not been well characterized at a large scale. Specifically, uveal melanoma diagnosis and outcomes in the emergency department (ED) has not been characterized. Methods: The Nationwide Emergency Department Sample was queried from the last quarter of 2015 to 2019 to identify patients with a primary diagnosis of uveal melanoma. Multivariable logistic regression, with patient- and hospital-level characteristics as covariates, was used to identify factors associated with increased risk of inpatient admission. Results: From the last quarter of 2015 to 2019, there were 1,274 ED encounters with a primary diagnosis of uveal melanoma. Most patients were less than 11 years old (43.4%), male (51.1%), or a Medicaid beneficiary (37.8%), and most belonged to a family in the lowest income quartile (32.0%). The median age of these patients was 35 years (IQR: 2-64). Most patients presented to hospitals in the South (53.9%), with a Trauma Level I designation (51.4%), and most to a metropolitan teaching hospital (89.1%). The most common ED outcomes were same-day discharge (61.6%) and admission to the inpatient setting (31.2%). Patients presenting to Trauma Level I hospitals were most likely to be admitted (odds ratio [OR]=2.21; p=0.031). The factors that were most significantly associated with decreased odds of inpatient admission were: patients who were not charged for services (often due to charity) (OR=0.13; p=0.040), Medicaid beneficiaries (OR=0.27; p=0.031), and private insurance beneficiaries (OR=0.34; p=0.047). Among the admitted patients, patients can be discharged to home with self-care (76.2%) or with home-health care (14.9%) or can be transferred to an intermediate-care facility (8.1%). The mean hospital length of stay was 5.7±0.6 days. In-hospital mortality rate for admitted patients was very low (0.8%). Conclusion: Uveal melanoma patient outcomes are closely related to insurance status, indicating socioeconomic factors as a modulator of patient outcomes. Citation Format: Alice A. Beneke, Kamil Taneja, Lauren Ladehoff, Kevin Root, Eric Toloza. Clinical outcomes of uveal melanoma patients in the emergency department [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3823.

The Increasing Burden of Emergency Department and Inpatient Consultations for "Papilledema".

Increasing incidence of idiopathic intracranial hypertension (IIH), overreported radiologic signs of intracranial hypertension, difficult access to outpatient neuro-ophthalmology services, poor insurance coverage, and medicolegal concerns have lowered the threshold for emergency department (ED) visits for "papilledema." Our objective was to examine referral patterns and outcomes of neuro-ophthalmology ED and inpatient consultations for concern for papilledema. At one university-based quaternary care center, all adults referred for "papilledema" over one year underwent a standardized ED "papilledema protocol." We collected patient demographics, final diagnoses, and referral patterns. Over 1 year, 153 consecutive patients were referred for concern for papilledema. After papilledema protocol, 89 of 153 patients (58%) had bilateral optic disc edema, among whom 89% (79/89) had papilledema (intracranial hypertension). Of the 38 of 153 (25%) consultations for suspected disorder of intracranial pressure without previous fundus examination (Group 1), 74% (28/38) did not have optic disc edema, 21% (8/38) had papilledema, and 5% (2/38) had other causes of bilateral disc edema. Of the 89 of 153 (58%) consultations for presumed papilledema seen on fundus examination (Group 2), 58% (66/89) had confirmed papilledema, 17% (15/89) had pseudopapilledema, and 9% (8/89) had other causes of bilateral optic disc edema. Of the 26 of 153 (17%) patients with known IIH (Group 3), 5 had papilledema and 4 required urgent intervention. The most common diagnosis was IIH (58/79). Compared with IIH, patients with secondary causes of intracranial hypertension were older (P = 0.002), men (P < 0.001), not obese (P < 0.001), and more likely to have neurologic symptoms (P = 0.002). Inpatient and ED consultations for "papilledema" are increasing. Of the 153 ED and inpatient neuro-ophthalmology consultations seen for "papilledema" over 1 year, one-third of patients with optic disc edema of unknown cause before presentation to our ED had new vision- or life-threatening disease, supporting the need for prompt identification and evaluation of optic disc edema in the ED. In the face of limited access to neuro-ophthalmologists, this study supports the need for emergency department access to expert eye-care evaluation or ocular fundus camera for prompt identification of optic disc edema and standardized evaluation for neurologic emergencies.

A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes.

Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments

Background: Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees. Methods: Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards. Results: There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time. Conclusion: Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.

Change of utilization of emergency department in children after lifting mask mandates in a single center in Korea

Purpose: We aimed to investigate changes in visiting patterns after the lifting of mask mandates in a single pediatric emergency medical center in Seoul, Korea.Methods: This retrospective study was based on the data of patients’ (≤ 18 years) visits to the emergency department (ED) of the center from January 1, 2022 through June 30, 2023. Clinical characteristics, Korean Triage and Acuity Scale (KTAS) level, ED outcomes, and length of stay were compared between before (March 20-June 30, 2022) and after (March 20-June 30, 2023) the lifting of mask mandates. The comparisons were iterated in the patients with infectious disease.Results: During the study period, a total of 18,654 children visited the ED. After the lifting of mask mandates, ED visits increased from 7,146 to 11,508 (61.0%; 95% confidence interval, 59.5-62.6; P &lt; 0.001). The increase was more prominent in the age of 2-5 years (82.9%), infectious diseases (175.3%), KTAS level 3 (127.7%), and length of stay shorter than 3 hours (78.8%-92.6%). The number of patients per hour increased by 151.2% for 5 patients or more and over 3,000% for 10 or more. Median length of stay decreased (2.3 hours [interquartile range, 1.2-4.1] to 1.9 hours [1.1-3.5]; P &lt; 0.001). The patients with infectious disease (n = 7,139) showed similar patterns of increase in the age of 2-5 years, KTAS level 3, and length of stay shorter than 3 hours, with an additional increase in the age of 6-18 years.Conclusion: After the lifting of mask mandates, pediatric visits increased by 61%, with the highest increase in children with mild infectious diseases on weekends and at night, and the proportion of more than 10 visits per hour significantly increased. We need urgent and realistic support measures from health authorities.

The effect of Ramadan on elderly patients presenting to the emergency department.

Background Patients visiting the emergency department (ED) may show variations by certain time periods such as Ramadan. We wished to ascertain whether Ramadan affects the ED presentations, clinical conditions and outcomes of patients aged 65 years or older. Methods . Patients aged 65 years or older who presented to ED in Ramadan and in the following month in 2018 were reviewed retrospectively. Results . A total of 1947 patients were enrolled, of whom 958 presented in Ramadan and 989 in the following month. The patients who presented in Ramadan most commonly (23.8%) presented between 8 p.m. and 11.59 p.m.; patients who presented in the following month most commonly (24%) presented between 8 a.m. and 11.59 a.m. (p=0.26). Complaints concerning the central nervous system (CNS) were more common in the month after Ramadan (p<0.0001). Diagnoses related to the cardiovascular system were more commonly made in Ramadan (p=0.037), whereas those related to CNS, otorhinolaryngology and oncology were more commonly made in the following month (p=0.0005, p=0.024 and p=0.003, respectively). No significant difference was found between the two groups with respect to outcomes (p=0.36). Compared to patients who presented in Ramadan, those that presented in the following month had a significantly longer ED stay (p=0.036). Conclusion . Our study detected no significant difference between the two groups with respect to the time of presentation and ED outcomes. Patients who presented in Ramadan had a lower incidence of CNS complaints; a higher incidence of cardiovascular diagnoses; lower incidences of CNS, oncological and otorhinolaryngological diagnoses and a significantly shorter length of ED stay.

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations. This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses. Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission. Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.

Epidemiology and outcomes of emergency department visits in systemic lupus erythematosus: Insights from the nationwide emergency department sample (NEDS).

Systemic lupus erythematosus (SLE) patients are prone to frequent emergency department (ED) visits. This study explores the epidemiology and outcomes of ED visits by patients with SLE utilizing the Nationwide Emergency Department Sample (NEDS). Using NEDS (2019), SLE ED visits identified using ICD-10 codes (M32. xx) were compared with non-SLE ED visits in terms of demographic and clinical features and primary diagnoses associated with the ED visits. Factors associated with inpatient admission were analyzed using logistic regression. Variations in ED visits by age and race were assessed. We identified 414,139 (0.35%) ED visits for adults ≥ 18years with SLE. ED visits with SLE comprised more women, Black patients, ages 31-50years, Medicare as the primary payer, and had higher comorbidity burden. A greater proportion of Black and Hispanic SLE patients who visited the ED were in the youngest age category of 18-30years (around 20%) compared to White patients (less than 10%). Non-White patients had higher Medicaid utilization (27%-32% vs 19% in White patients). Comorbidity patterns varied based on race, with more White patients having higher rates of hyperlipidemia and ischemic heart disease (IHD) and more Black patients having chronic kidney disease (CKD), hypertension, and heart failure. Categorizing by race, SLE/connective tissue disease (CTD) and infection were the most prevalent primary ED diagnosis in non-White and White patients, respectively. Age ≥ 65years, male sex, and comorbidities were linked to a higher risk of admission. Black race (OR 0.86, p = .01) and lowest income quartile (OR 0.78, p = .003) had lower odds of inpatient admission. Infection and SLE/CTD were among the top diagnoses associated with ED visits and inpatient admission. Despite comprising a significant proportion of SLE ED visits, Black patients had lower odds of admission. While the higher prevalence of older age groups, hyperlipidemia, and IHD among White patients may partly explain the disparate results, and further study is needed to understand the role of other factors including reliance on the ED for routine care compared among Black patients, differences in insurance coverage, and potential socioeconomic biases among healthcare providers.

Abstract 11897: Admission Rates for Pediatric Supraventricular Tachycardia From the Emergency Department Are Affected by Primary Insurance Payor: An Analysis of the NEDS Database

Introduction: Supraventricular tachycardia (SVT) is the most common arrhythmia in children and often requires emergency department (ED) care. Recent data highlight disparities in access to care for pediatric patients with SVT, though the association of socioeconomic factors with ED outcomes remains unclear. Hypothesis: Outcomes of ED encounters for pediatric SVT will differ by insurance payor. Methods: We performed a retrospective cohort study utilizing encounter-level data from the 2006-2018 US Nationwide Emergency Department Sample (NEDS). All encounters for patients age 0-18 years with a primary diagnosis of SVT were evaluated, excluding those with diagnoses of congenital heart disease or cardiomyopathy. The primary exposure was insurance payor: private vs. public. The primary outcome was hospital admission/transfer. Secondary outcomes included inpatient length of stay (LOS), procedures (cardioversion, catheter ablation), and mortality. Logistic regression models evaluated the association of payor with outcomes, including the following covariates: age, hospital teaching status, hospital region, patient residence, and patient income. Results: A total of 38,896 ED encounters were analyzed: median age 11.5 years (IQR 6-15); 48% male; 53% private payor, 38% public payor. Encounters with public payor had a higher rate of admit/transfer than private (24% vs. 18%, p&lt;0.0001). There were no differences in LOS (2.5 days public vs. 1.8 days private, p= 0.6) or procedures by payor; there were no mortalities. In multivariate analysis, public payor was an independent predictor of admission/transfer (OR 1.6, 95% CI 1.2-2.2). Patient age was also associated with admission/transfer, with all age groups less likely to undergo admission/transfer compared to age &lt; 1 year: age 1-4, OR 0.3, 95% CI 0.2-0.6; age 5-8, OR 0.1, 95% CI 0.1-0.2; age 9-12, OR 0.1, 95% CI 0.1-0.2; age 13-18, OR 0.1, 95% CI 0.1-0.2. Conclusions: This analysis demonstrates that public payor is associated with higher rates of hospital admission/transfer for pediatric SVT, independent of age. Though we cannot evaluate why publicly insured patients are admitted more often, it may be due to more severe illness caused by delays in care for SVT. If so, this should be a target for intervention.

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population.

Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Demographic and Clinical Characteristics of Earthquake Victims Presented to the Emergency Department with and without Crush Injury upon the 2023 Kahramanmaraş (Turkey) Earthquake.

Earthquakes are sudden-onset natural disasters that are associated with substantial material damage, resulting in the collapse of built environment with a high rate of mortality, injury, and disability. Crush syndrome, which can be seen after devastating earthquakes, can lead to acute kidney injury (AKI) and patients may require amputation, fasciotomy, and dialysis. Supportive treatment has an important role in the prognosis of these patients. The aim of this study was to investigate the demographic and clinical characteristics of traumatic earthquake survivors admitted to the emergency department (ED) of a hospital, which was close to the earthquake zone but not affected by the earthquake, after the February 6, 2023 Kahramanmaraş (Turkey) earthquakes. This study was conducted by retrospectively analyzing the data of 1,110 traumatized earthquake survivors admitted to the ED of a tertiary care university hospital from February 6th through February 20th, 2023. Age; gender; time of presentation; presence of comorbid diseases; ED triage category; duration of stay under debris; presence of additional trauma; laboratory tests; presence of AKI; presence of crush injury and injury sites; supportive treatment (fluid replacement and intravenous [IV] sodium bicarbonate); need for amputation, dialysis, and fasciotomy; duration of hospitalization; and outcome of ED were evaluated. Of the 1,110 traumatic victims in this study, 55.5% were female patients. The mean age of the patients was 45.94 (SD = 16.7) years; the youngest was 18 years old and the oldest was 95 years old. Crush injury was detected in 18.8% and AKI in 3.0% of the patients. Dialysis, amputation, and fasciotomy were required in 1.6%, 2.8%, and 1.4% of the patients, respectively. In total, 29.2% of patients were hospitalized, including 2.9% admitted to the intensive care unit (ICU) and 26.3% to the relevant ward. In total, 0.3% of the patients included in the study died at ED. Post-earthquake patients may present with crush injury, AKI may develop, and fasciotomy, amputation, and dialysis may be needed, so hospitals and EDs should be prepared for natural disasters such as earthquakes.

Clinical and economic effectiveness of a pharmacy and primary care collaborative transition of care program

BackgroundPrimary care pharmacists are uniquely positioned to improve care quality by intervening within care transitions in the postdischarge period. However, additional evidence is required to demonstrate that pharmacist-led interventions can reduce health care utilization in a cost-effective manner. The study’s objective was to evaluate the clinical and economic effectiveness of a pharmacy-led transition of care (TOC) program within a primary care setting. MethodsThis cluster randomized trial was conducted between 2019 and 2021 and included three primary care practices. Eligible patients were ≥18 years of age and at high risk of readmission. The multifaceted pharmacy intervention included medication reconciliation, comprehensive medication review, and patient and provider follow-up. The primary composite endpoint included hospital readmissions and emergency department (ED) visits within 30 days of discharge. Differences in outcomes were modeled using a generalized estimated equations approach and outcomes were assumed to be distributed as a Poisson random variable. A cost-benefit analysis was embedded within the study and estimated economic outcomes from a provider group/health system perspective. Cost measures included: net benefit, benefit to cost ratio (BCR), and return on investment (ROI). ResultsOf 300 eligible patients, 36 were in the intervention group and 264 in the control group. The intervention significantly reduced the primary composite outcome of all-cause readmissions and ED visits within 30 days (adjusted incidence rate ratio [aIRR], 0.54; 95% CI, 0.44–0.66; P < 0.001). There were significant reductions in both 30-day all-cause readmissions (aIRR, 0.64; 95% CI, 0.60–0.67; P < 0.001) and ED visits (aIRR, 0.25; 95% CI, 0.20, 0.31; P < 0.001) between groups. The net benefit of the intervention was $9,078, with a BCR of 2.11 and a ROI of 111%. Sensitivity analyses were robust to changes in economic inputs. ConclusionThis care transition program had positive clinical and economic benefits, providing further support for the essential role pharmacists demonstrate in providing TOC services.

Performance of the Interagency Integrated Triage Tool in a resource-constrained emergency department during the COVID-19 pandemic

BackgroundThe Interagency Integrated Triage Tool (IITT) is a three-tier triage instrument recommended by the World Health Organization, but only the pilot version of the tool has been comprehensively assessed for its validity and reliability. This study sought to evaluate the performance of the IITT in a resource-constrained emergency department (ED) during the COVID-19 pandemic. MethodsThis prospective observational study was conducted at ANGAU Memorial Provincial Hospital in Lae, Papua New Guinea. The study period commenced approximately six weeks after introduction of the IITT, coinciding with a major COVID-19 wave. The primary outcome was sensitivity for the detection of time-critical illness, defined by eight pre-specified conditions. Secondary outcomes included the relationship between triage category and disposition. Inter-rater reliability was assessed using Cohen’s Kappa. ResultsThere were 759 eligible presentations during the study period. Thirty patients (4.0%) were diagnosed with one of the eight pre-specified time-critical conditions and 21 were categorised as red or yellow, equating to a sensitivity of 70.0% (95%CI 50.6–85.3). There was a clear association between triage category and disposition, with 22 of 53 red patients (41.5%), 72 of 260 yellow patients (27.7%) and 22 of 452 green patients (4.9%) admitted (p = <0.01). Negative predictive values for admission and death were 95.1% (95%CI 92.7–96.9) and 99.3% (95%CI 98.1–99.9) respectively. Among a sample of 106 patients, inter-rater reliability was excellent (κ = 0.83) and the median triage assessment time was 94 seconds [IQR 57–160]. ConclusionIn this single-centre study, the IITT’s sensitivity for the detection of time-critical illness was comparable to previous evaluations of the tool and within the performance range reported for other triage instruments. There was a clear relationship between triage category and disposition, suggesting the tool can predict ED outcomes. Health service pressures related to COVID-19 may have influenced the findings.

Patient Characteristics Associated with Hospital Admission or Antiarrhythmic Medication Changes After Emergency Department Evaluation of Supraventricular Tachycardia.

Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED. A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children's hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications. We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4). Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.

Emergency department patient-centred care perspectives from deaf and hard-of-hearing patients.

Deaf and hard-of-hearing (DHH) patients are a priority population for emergency medicine health services research. DHH patients are at higher risk than non-DHH patients of using the emergency department (ED), have longer lengths of stay in the ED and report poor patient-provider communication. This qualitative study aimed to describe ED care-seeking and patient-centred care perspectives among DHH patients. This qualitative study is the second phase of a mixed-methods study. The goal of this study was to further explain quantitative findings related to ED outcomes among DHH and non-DHH patients. We conducted semistructured interviews with 4 DHH American Sign Language(ASL)-users and 6 DHH English speakers from North Central Florida. Interviews were transcribed and analysed using a descriptive qualitative approach. Two themes were developed: (1) DHH patients engage in a complex decision-making process to determine ED utilization and (2) patient-centred ED care differs between DHH ASL-users and DHH English speakers. The first theme describes the social-behavioural processes through which DHH patients assess their need to use the ED. The second theme focuses on the social environment within the ED: patients feeling stereotyped, involvement in the care process, pain communication, receipt of accommodations and discharge processes. This study underscores the importance of better understanding, and intervening in, DHH patient ED care-seeking and care delivery to improve patient outcomes. Like other studies, this study also finds that DHH patients are not a monolithic group and language status is an equity-relevant indicator. We also discuss recommendations for emergency medicine. This study convened a community advisory group made up of four DHH people to assist in developing research questions, data collection toolsand validation of the analysis and interpretation of data. Community advisory group members who were interested in co-authorship are listed in the byline, with others in the acknowledgements. In addition, several academic-based co-authors are also deaf or hard of hearing.

Sociodemographic Disparities in Queue Jumping for Emergency Department Care

Emergency department (ED) triage models are intended to queue patients for treatment. In the absence of higher acuity, patients of the same acuity should room in order of arrival. To characterize disparities in ED care access as unexplained queue jumps (UQJ), or instances in which acuity and first come, first served principles are violated. Retrospective, cross-sectional study between July 2017 and February 2020. Participants were all ED patient arrivals at 2 EDs within a large Northeast health system. Data were analyzed from July to September 2022. UQJ was defined as a patient being placed in a treatment space ahead of a patient of higher acuity or of a same acuity patient who arrived earlier. Primary outcomes were odds of a UQJ and association with ED outcomes of hallway placement, leaving before treatment complete, escalation to higher level of care while awaiting inpatient bed placement, and 72-hour ED revisitation. Secondary analysis examined UQJs among high acuity ED arrivals. Regression models (zero-inflated Poisson and logistic regression) adjusted for patient demographics and ED operational variables at time of triage. Of 314 763 included study visits, 170 391 (54.1%) were female, the mean (SD) age was 50.46 (20.5) years, 132 813 (42.2%) patients were non-Hispanic White, 106 401 (33.8%) were non-Hispanic Black, and 66 465 (21.1%) were Hispanic or Latino. Overall, 90 698 (28.8%) patients experienced a queue jump, and 78 127 (24.8%) and 44 551 (14.2%) patients were passed over by a patient of the same acuity or lower acuity, respectively. A total of 52 959 (16.8%) and 23 897 (7.6%) patients received care ahead of a patient of the same acuity or higher acuity, respectively. Patient demographics including Medicaid insurance (incident rate ratio [IRR], 1.11; 95% CI, 1.07-1.14), Black non-Hispanic race (IRR, 1.05; 95% CI, 1.03-1.07), Hispanic or Latino ethnicity (IRR, 1.05; 95% CI, 1.02-1.08), and Spanish as primary language (IRR, 1.06; 95% CI, 1.02-1.10) were independent social factors associated with being passed over. The odds of a patient receiving care ahead of others were lower for ED visits by Medicare insured (odds ratio [OR], 0.92; 95% CI, 0.88-0.96), Medicaid insured (OR, 0.81; 95% CI, 0.77-0.85), Black non-Hispanic (OR, 0.94; 95% CI, 0.91-0.97), and Hispanic or Latino ethnicity (OR, 0.87; 95% CI, 0.83-0.91). Patients who were passed over by someone of the same triage severity level had higher odds of hallway bed placement (OR, 1.01; 95% CI, 1.00-1.02) and leaving before disposition (OR, 1.02; 95% CI, 1.01-1.04). In this cross-sectional study of ED patients in triage, there were consistent disparities among marginalized populations being more likely to experience a UQJ, hallway placement, and leaving without receiving treatment despite being assigned the same triage acuity as others. EDs should seek to standardize triage processes to mitigate conscious and unconscious biases that may be associated with timely access to emergency care.

Shock index in the emergency department as a predictor for mortality in COVID-19 patients: A systematic review and meta-analysis

BackgroundThe shock index (SI) ratio serves as a straightforward predictor to identify patients who are either at risk of or experiencing shock. COVID-19 patients with shock face increased mortality risk and reduced chances of recovery. This review aims to determine the role of SI in the emergency department (ED) to predict COVID-19 patient outcomes. MethodsThe systematic search was conducted in PubMed, ProQuest, Scopus, and ScienceDirect on June 16, 2023. We included observational studies evaluating SI in ED and COVID-19 patient outcomes. Random-effect meta-analysis was done to generate odds ratios of SI as the predictor of intensive care unit (ICU) admission and mortality. The sensitivity and specificity of SI in predicting these outcomes were also pooled, and a summary receiver operating characteristics (sROC) curve was generated. ResultsA total of eight studies involving 4557 participants were included in the pooled analysis. High SI was found to be associated with an increased risk of ICU admission (OR 5.81 [95%CI: 1.18–28.58], p = 0.03). Regarding mortality, high SI was linked to higher rates of in-hospital (OR 7.45 [95%CI: 2.44–22.74], p = 0.0004), within 30-day (OR 7.34 [95%CI: 5.27–10.21], p < 0.00001), and overall (OR 7.52 [95%CI: 3.72–15.19], p < 0.00001) mortality. The sensitivity and specificity of SI for predicting ICU admission were 76.2% [95%CI: 54.6%–89.5%] and 64.3% [95%CI: 19.6%–93.0%], respectively. In terms of overall mortality, the sensitivity and specificity were 54.0% (95%CI: 34.3%–72.6%) and 85.9% (95%CI: 75.8%–92.3%), respectively, with only subtle changes for in-hospital and within 30-day mortality. Adjustment of SI cut-off to >0.7 yielded improved sensitivity (95%CI: 78.0% [59.7%–89.4%]) and specificity (95%CI: 76.8% [41.7%–93.9%]) in predicting overall mortality. ConclusionSI in emergency room may be a simple and useful triage instrument for predicting ICU admission and mortality in COVID-19 patients. Future well-conducted studies are still needed to corroborate the findings of this study.

Pharmacist involvement in blood culture follow up for patients discharged from the emergency department

Study objectiveThis study evaluates the time to attempted patient contact for positive blood cultures in patients discharged from the Emergency Department (ED) resulting when an Emergency Medicine (EM) pharmacist is on-duty compared to off-duty. MethodsThis single center, retrospective study included patients who were discharged from the ED and had subsequent positive blood cultures. Blood cultures were reviewed utilizing an algorithm previously approved and implemented by an interdisciplinary team in 2016. Standard practice was for the microbiology lab to notify the ED charge nurse of the positive blood culture, however, the algorithm placed the pharmacist as the responsible reviewer when on duty, leaving charge nurses and physicians as the responsible reviewers when a pharmacist was off duty and not on site. The primary outcome was time from ED notification of the positive gram stain of the blood culture to first attempted patient contact; we compared this outcome for cultures resulting when an EM pharmacist was on duty to those resulting when an EM pharmacist was off duty. Despite being off duty, a pharmacist may have reviewed these cultures if they remained unaddressed when the pharmacist returned on-site. In this case, the blood culture review was included in the off-duty cohort. Secondary outcomes included evaluation for appropriateness of the recommendation made to the patient during contact, 30-day infection-related readmission rates, patient's adherence to the recommendations, and barriers to patient contact. An infectious disease attending physician independently reviewed cases where the algorithm was not followed. ResultsA total of 127 patients identified by a query of our institution's database were screened against inclusion/exclusion criteria and 56 were excluded, leaving 71 patients for final analysis (54 and 17 in the on- and off-duty cohorts, respectively). Baseline demographics with respect to sex, age and risk factors for bacteremia were not different between groups, except there were more immunocompromised patients in the on-duty cohort (35.2%) compared to off-duty cohort (5.9%) [p = 0.01]. Median [IQR] time to first attempted patient contact was significantly shorter in the on-duty cohort at 0.8 h [0.4–2.8] vs 5.6 h [1.4–11.7] (p = 0.025). A pharmacist acted upon 93% of all cultures, including several resulting during off-duty hours. Secondary outcomes did not differ. Fourteen (25.9%) of on-duty cultures and six (35.3%) of off-duty cultures were deemed contaminants. Two recommendations in the off-duty group were inappropriate based on the infectious disease attending physician review. The lack of active voicemail was the main barrier to contacting a patient. ConclusionsIn patients discharged from the ED with subsequent positive blood cultures, time to attempted patient contact was significantly shorter when a pharmacist was on-duty. Our data emphasizes the importance of having a standardized practice in place to optimize ED patient care and outcomes and the benefit of a pharmacist's involvement in the process.