Emergency Department Presentation Research Articles

Impact of care coordination on service utilisation for children with medically complex cerebral palsy.

Complex care programmes for children with medically complex cerebral palsy (CP) exist; however, evidence for their impact is limited. This study (i) explored the impact of The Royal Children's Hospital Complex Care Hub (CCH) on hospital service utilisation rates over a 3-year period for children with medically complex CP compared with those eligible but received routine care, and (ii) compared health, disability and socio-demographic characteristics of children and their families in both groups. Electronic medical record data from 78 children (mean age 9.43 years, females n = 37) with medically complex CP who accessed CCH services, and 92 (mean age 10.86 years, females, n = 39) who received routine care were included. Multivariable regression was used to analyse service utilisation: number of emergency department (ED) presentations, length/number of inpatient and intensive care unit admissions and number/type of hospital appointments. Critical health-care needs, functioning/disability profile and child/family demographics for each group were compared. More children in the CCH group had a mixed motor type (73.1% vs. 15.2%), were classified within Gross Motor Function Classification System level V (76.9% vs. 34.8%), had respiratory, nutrition and social support needs and epilepsy. Children receiving CCH services had higher service utilisation rates; ED presentations (rate ratio (RR) = 1.81, 95% confidence interval (CI): 1.09-3.01), inpatient admissions (RR = 2.77, 95% CI: 2.01-3.83), outpatient encounters (RR = 1.69, 95% CI: 1.31-2.18) and telephone encounters (RR = 6.05, 95% CI: 4.56-8.02). Children with medically complex CP accessing a complex care service have higher service utilisation rates yet have more complex clinical presentations and higher support needs.

A Tale of 102,726 Messages: Characterizing the Modern Urologist's Portal Message Burden After Common Urologic Surgeries.

We aimed to characterize patient portal messaging use after urologic surgery to identify administrative burden and evaluate postoperative clinical associations. Epic was queried for all urologic surgeries performed at the Mayo Clinic enterprise between 2019 and 2022. Data from the highest volume procedures were extracted including patient-generated portal messages to their provider and emergency department (ED) visits within 6 months of surgery. Factors associated with portal users and message volume, as well as the impact of portal use on risk of subsequent ED visit, were evaluated. We analyzed data from 23,621 urologic procedures, which generated 102,726 patient portal messages within 6 months of surgery. We found that 55% of our cohort sent at least 1 message. Stratifying by subspecialty, endourologic surgeries generated the fewest number of messages per surgery (3.83; SD, 8.76), whereas female pelvic medicine and reconstructive surgeries yielded the most (6.05; SD, 10.92). Younger age, female sex, and White race were associated with increased portal utilization. Multivariable time-to-event analysis revealed a 33% reduction in the risk of ED presentation within 90 days after surgery for patients using the patient portal compared with those who did not. While only half of patients sent portal messages after surgery, active users showed a 33% reduction in ED visits, suggesting its potential to reduce health care utilization. Encouraging broader portal adoption can improve outcomes. However, the message burden for urologists necessitates solutions. Resource allocation should prioritize strategies to help urologists manage messages while preserving the established clinical benefits.

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.

Prediction of emergency department presentations for acute coronary syndrome using a machine learning approach

The relationship between weather and acute coronary syndrome (ACS) incidence has been the subject of considerable research, with varying conclusions. Harnessing machine learning techniques, our study explores the relationship between meteorological factors and ACS presentations in the emergency department (ED), offering insights into seasonal variations and inter-day fluctuations to optimize patient care and resource allocation. A retrospective cohort analysis was conducted, encompassing ACS presentations to Dutch EDs from 2010 to 2017. Temporal patterns were analyzed using heat-maps and time series plots. Multivariable linear regression (MLR) and Random Forest (RF) regression models were employed to forecast daily ACS presentations with prediction horizons of one, three, seven, and thirty days. Model performance was assessed using the coefficient of determination (R²), Mean Absolute Error (MAE), and Mean Absolute Percentage Error (MAPE). The study included 214,953 ACS presentations, predominantly unstable angina (UA) (94,272; 44%), non-ST-elevated myocardial infarction (NSTEMI) (78,963; 37%), and ST-elevated myocardial infarction (STEMI) (41,718; 19%). A decline in daily ACS admissions over time was observed, with notable inter-day (estimated median difference: 41 (95%CI = 37–43, p = < 0.001) and seasonal variations (estimated median difference: 9 (95%CI 6–12, p = < 0.001). Both MLR and RF models demonstrated similar predictive capabilities, with MLR slightly outperforming RF. The models showed moderate explanatory power for ACS incidence (adjusted R² = 0.66; MAE (MAPE): 7.8 (11%)), with varying performance across subdiagnoses. Prediction of UA incidence resulted in the best-explained variability (adjusted R² = 0.80; MAE (MAPE): 5.3 (19.1%)), followed by NSTEMI and STEMI diagnoses. All models maintained consistent performance over extended prediction horizons. Our findings indicate that ACS presentation exhibits distinctive seasonal changes and inter-day differences, with marked reductions in incidence during the summer months and a distinct peak prevalence on Mondays. The predictive performance of our model was moderate. Nonetheless, we obtained good explanatory power for UA presentations. Our model emerges as a potentially valuable supplementary tool to enhance ED resource allocation or future predictive models predicting ACS incidence in the ED.

Mapping the patient journey: utilizing clinical informatics for a conceptual approach to identify aspects of emergency department access block

BackgroundThe study aims to map the patient journey in a regional Emergency Department (ED), identify factors causing extended Length of Stay (LOS) in ED during pre-COVID (2016–2019), COVID (2020–2022) and post-COVID (2023), and analyse the patient journey using clinical informatics. Through systematic analysis and root cause identification, the study seeks to establish a learning health system. This system will enhance patient experiences and improve timely and effective care delivery.MethodsSummarized data on ED presentations data were sourced from January 2016 to August 2023 for a 294-bed regional hospital in New South Wales (NSW). The patient’s journey from ED to admission inpatient wards was analysed using clinical informatics. The time spent in each segment of the ED journey was analysed separately and subdivided by specialty for further analysis.ResultsPatient characteristics remained similar year on year. The average ED LOS increased from 5.59 h during the pre-COVID period (2016–2019) to 8.48 h during the COVID period (2020–2022) and 8.52 h during the post-COVID period (2023). The hospital’s bed occupancy rate remained consistent before and during the COVID-19 pandemic, with a slight improvement afterwards, except for a decrease in 2020. The occupancy rate for ED-accessible beds during the pre-COVID period is higher than during the COVID and post-COVID periods. The admission from ED to Inpatient wards decreased from 35% pre-COVID to 28% during COVID. Of the total LOS, the ‘Bed Request’ to ‘Bed Ready’ time segment increased from 11.41% in 2016 to 41.19% in 2022. The admission of medical specialty consistently made up most admissions (32%) which increased during the COVID. The medical specialty also spent the most time in the ED, peaking at 880 min in 2022.ConclusionClinical Informatics is an effective tool to visualise the bottlenecks in clinical workflows. The ‘Bed Request’ to ‘Bed Ready’ time segment was the largest contributor to ED LOS and may have been attributed to a lack of bed availability. Patients took an average of 50 min to be transferred to Inpatient wards upon admission. Future studies could utilize insights gained to develop specific key performance indicators aimed at improving ED LOS. Moreover, we are currently working on improving real-time access to inpatient beds but are currently hampered by the ‘manual update’ of bed status that is controlled by the individual wards. We aim to build an automated system that can monitor and update bed availability (e.g., patient discharge) with minimal human intervention.

A-307 Clinical utility of serum calprotectin in febrile infants presenting to the Emergency Department

Abstract Background Antimicrobial stewardship involves a delicate balance between the risk of undertreating individuals and the potential societal burden of overprescribing antimicrobials. However, early and accurate diagnosis of bacterial infections in critically ill patients is challenging, as the clinical manifestation is non-specific. Furthermore, the results from microbial cultures may be delayed, resulting in delayed antibiotic treatment, which is associated with increased mortality. Neutrophil activation is a major response to bacterial infection and calprotectin is the most abundant protein in the cytosolic fraction of neutrophils, shown as an early marker for neutrophil activation. The objective of this study was to evaluate the clinical performance of serum calprotectin in identifying bacterial infection in febrile infants presenting to an Emergency Department (ED) relative to other common biomarkers of infection. Methods 141 infants aged 28-90 days with suspected infectious disease presenting to the ED at The Hospital for Sick Children in Toronto, were included in this non-interventional investigation. All biomarkers except calprotectin were used in the routine clinical adjudication of the final diagnosis. Residual serum specimens collected as part of the standard care pathway were stored at -80°C prior to analysis of serum calprotectin using GCAL® assay (Gentian AS, Norway). Chart review was completed for key variables including, age (days), sex, chief complaint and temperature at ED presentation, and available laboratory test results (i.e., C-reactive protein and procalcitonin (Architect, Abbott Diagnostics), WBC count and neutrophil count (XN3000, Sysmex Europe GmbH), urinary leukocytes and nitrates, blood and/or urine bacterial culture). Final diagnosis, admission status, and antibiotic prescription at ED discharge were also extracted. Results Final discharge diagnosis in patient population included bacterial infection (n=23), viral infection (n=22), fever of unknown source (n=54) and other/unknown diagnosis (n=42). Antibiotics were prescribed in 36 cases, although bacterial infection could only be confirmed in 23 cases when final diagnosis was made. Statistically significant differences were observed in serum calprotectin (p&amp;lt;0.001), procalcitonin (p&amp;lt;0.001), and CRP (p&amp;lt;0.001) in patients with bacterial infections compared to patients with other discharge diagnoses. ROC curve analysis was performed for the identification of bacterial infections in the entire clinical cohort (n=141) and in only patients with laboratory confirmed bacterial or viral infection (n=41). Calprotectin and procalcitonin showed higher specificity than CRP and WBC count for differentiation between bacterial and viral infection in both cohorts. Performance of calprotectin in detection of bacterial infections was comparable to the performance of CRP, slightly better than performance of procalcitonin and superior to WBC count. Conclusions In this cohort, one third of the children that were prescribed antibiotics did not have confirmed bacterial infection. Hence, there is a need for adequate diagnostic tools to help discriminate between various kinds of infections. This study confirms serum calprotectin as a valuable biomarker for differentiation between types of infection and estimation of disease severity in febrile infants. Access to fast and accurate analysis of circulating calprotectin, combined with good clinical performance has the potential to make this biomarker a valuable complement to the current diagnostics of patients with bacterial infections and sepsis.

Demographics and scope of Australian emergency department physiotherapists

QuestionsTo provide workforce data on the status of Australian Emergency Department (ED) physiotherapy practice, including physiotherapist demographic data, staffing levels and funding sources. Evaluate the scope of practice currently undertaken by ED physiotherapists and alignment of ED physiotherapy service provision with demand levels.DesignCross sectional survey.ParticipantsAustralian physiotherapists working within an Australian ED.Outcome measuresWorkforce data, scope of practice and alignment of physiotherapy service provision to ED presentations and demand.Results94 Australian ED physiotherapists completed the survey, 76.9% were working as primary contact clinicians. They had a diverse scope of practice, 100% perform mobility assessments, 89.9% provide care for paediatric patients and 10.1% were involved in administration of medications. 86.2% of participants (75/87) reported working within a service model that provided seven-day per week physiotherapy coverage to ED.ConclusionThe sample of ED physiotherapists were found to be experienced and highly trained clinicians with a diverse scope of practice, who are well placed to meet the unpredictable and highly variable patient caseload of Australian EDs.

A-017 Clinical Performance Evaluation of the Atellica IM High-Sensitivity Troponin I Assay to Aid in Risk Stratification for All-Cause Mortality and Major Adverse Cardiac Events

Abstract Background Cardiac troponin I (cTnI) is the only troponin isoform present in the myocardium, where it binds to actin and inhibits actin and myosin interaction. Upon myocardial injury, cTnI is released into circulation and serial measurements can be used to aid in the diagnosis of acute myocardial infarction (AMI). In addition, in patients presenting with signs and symptoms of acute coronary syndrome (ACS), elevated cTnI levels provide useful prognostic information relative to short and long-term risk of all-cause mortality (ACM) and major adverse cardiac events (MACE). The objective of this study was to evaluate the clinical performance of the Atellica® IM TNIH assay to aid in risk stratification for ACM/MACE*. Methods Patients from 29 emergency departments (ED) across the United States presenting with signs and symptoms suggestive of ACS were followed for 30-, 90-, and 365-day progression to ACM/MACE (consisting of myocardial infarction, urgent revascularization, cardiac death, or heart failure hospitalization). At each timepoint, the risk (cumulative incidence) and hazard ratios were calculated for populations with baseline cTnI levels ≤ or &amp;gt; the 99th percentile value. Kaplan-Meier curves were generated to display the absolute risk (cumulative incidence) of ACM/MACE outcomes. Analyses were performed for all enrolled patients (entire population) and separately for the entire population excluding those with an adjudicated AMI at presentation. Analyses were performed separately for both serum and plasma (lithium heparin) sample types. Results For the Entire Population cohort, the binary baseline TNIH result (TNIH &amp;gt; overall 99th percentile or ≤ overall 99th percentile) was significantly associated with 30-, 90-, and 365-day cumulative ACM/MACE (p-value&amp;lt;0.0125) for both plasma and serum samples. For plasma samples, risk difference increased from 6.27% at day 30 to 19.62% at day 365. For serum samples, risk difference increased from 6.24% at day 30 to 18.71% at day 365. Cox proportional hazard regression analysis compared the TNIH 99th percentile groups in their hazard of experiencing an ACM/MACE event in the 30-, 90-, and 365-days post ED presentation. For plasma samples, the hazard of ACM/MACE for subjects with cTnI values above the TNIH 99th percentile was relatively constant at each follow-up interval as more than double the rate of subjects below the 99th percentile; hazard ratios ranged between 2.81 (p-value&amp;lt;0.0001) and 3.49-fold (p-value&amp;lt;0.0001) for the three follow up visits. For serum samples, the hazard ratios were between 2.69 (p-value&amp;lt;0.0001) and 3.28-fold (p-value&amp;lt;0.0001) for the three follow up visits. Similar results were obtained for the Entire Population Excluding Subjects with Adjudicated AMI During Initial Presentation cohort. Conclusions The Atellica IM TNIH assay can be used in the detection of myocardial injury and can aid in risk stratification for 30-, 90-, and 365-day all-cause mortality (ACM) and major adverse cardiac events (MACE) in patients presenting with signs and symptoms suggestive of acute coronary syndrome (ACS). *This prognostic claim is not available in the United States.

Outcomes After Total Knee Arthroplasty in Patients With a History of Patella Fracture: A Propensity Score-Matched Analysis.

Posttraumatic osteoarthritis is a common indication for total knee arthroplasty (TKA). The purpose of this study was to evaluate the association between a history of patella fracture and postoperative complication rates after TKA. Patients diagnosed with a patella fracture before undergoing TKA were identified from a large national database and matched to a control cohort using propensity scoring. Rates of medical complications occurring within 90 days of TKA and surgery-related complications occurring within 1 year of TKA were compared using odds ratios. Healthcare utilization outcomes including 90-day emergency department (ED) presentation, hospital readmission, and total cost were also compared. Compared with a propensity-matched control cohort, TKA patients with a history of patella fracture had a lower incidence of pulmonary embolism (OR 0.74, P = 0.0442) and higher incidences of periprosthetic joint infection (OR 1.68, P < 0.0001), revision surgery (OR 1.84, P < 0.0001), dislocation (OR 1.61, P = 0.026), lysis of adhesions (OR 2.21, P = 0.0082), and wound disruption (OR 1.52, P < 0.0001). A history of patella fracture was also associated with an increased rate of ED presentation (OR 1.08, P = 0.0454) and increased total cost ($14,359 vs. $12,786, P = 0.0003). A history of patella fracture is associated with early surgery-related complications after TKA including periprosthetic joint infection, revision surgery, dislocation, lysis of adhesions, and wound disruption. Healthcare utilization is increased among these patients with higher rates of ED presentation and increased total cost. These findings allow for more accurate risk stratification and counseling of patients. III, Retrospective review.

Poisoning and envenomation linkage to evaluate outcomes and clinical variation in Australia (PAVLOVA): a longitudinal data-linkage cohort of acute poisonings, envenomations, and adverse drug reactions in New South Wales, Australia, 2011–2020

Introduction Poisoning is a leading cause of morbidity and mortality that is increasing in many countries. Better data are needed to understand epidemiology and outcomes of poisoning. This work describes a new poisoning data linkage cohort in New South Wales, Australia (population approximately 8 million). Methods This is a longitudinal health record linkage, 2011–2020, including data from: ambulance call-outs, emergency department presentations, hospital admissions, death registrations, the poisons centre, and four tertiary toxicology units. Individuals with poisoning, venomous animal/plant exposures, or adverse drug reaction events were included. Results There were 845,217 linkable events relating to 400,642 ambulance, 688,484 emergency department, 682,013 admission, 40,456 toxicology, and 11,879 death records. There were 572,841 people with events; the median age at the time of first event was 57 years, and 51.9% were female. Events leading to patient admission were most commonly adverse drug reactions (n = 511,263), intentional poisonings (n = 68,646), unintentional poisonings (n = 54,840) and animal/plant exposures (n = 11,092). Demographics varied by cause: intentional poisoning (median age 33 years, 61.7% female); unintentional poisoning/animals/plants (median age 43 years, 45% female); and adverse drug reactions (median age 70 years, 54% female). Adolescent females had highest rates of intentional poisoning, while unintentional poisoning had a bimodal distribution, highest in children <5 years old and males aged 20 to 50 years. Substance use disorders were documented comorbidities for 44% of intentional poisoning, 29% of unintentional poisoning, and 13% of adverse drug reaction-related admissions; mood disorders were documented for 54%, 17% and 10% of these admissions, respectively. Discussion Poisonings and hospitalised adverse drug reactions are common in New South Wales, affecting approximately 8% of the population in 10 years. This linkage improves understanding of poisoning risks and outcomes in Australia. Conclusions This novel data linkage provides a unique opportunity to study poisoning across multiple settings for an individual over an extended period.

Epidemiological comparison of emergency department presentations with seasonal influenza or COVID-19 and an outcome of intensive care admission or death: A population-based records linkage study in New South Wales, Australia

COVID-19 and seasonal influenza are endemic causes of morbidity and mortality. This study aimed to compare the epidemiology of severe illness and risk of death among patients following emergency department (ED) presentation with either infection. De-identified, population-based, emergency department records in New South Wales, Australia, were probabilistically linked to population-level health outcome databases for the period 1 January 2015 to 28 February 2023. Included were patients allocated an ED diagnosis consistent with an acute respiratory infection. Logistic regression was used to examine the association of infecting virus with risk of a severe outcome (intensive care unit admission or death). Influenza infection was notified in 2335 and COVID-19 in 5053 patients with a severe outcome. The age distribution was similar for both viruses, except in <15-year-olds, where severe influenza was nearly three times more frequent. Overall, the odds of death among patients with COVID-19 was 1.65 (95% CI 1.43, 1.89) times higher than among those with influenza. This declined to 1.49 (95% CI 1.08, 2.06) times during the COVID-19 Omicron variant period. The Omicron variant arrived when background population COVID-19 vaccination coverage was >90%. Despite that, death was more frequent for COVID-19 than influenza.

Viral Determinants of Childhood Asthma Exacerbation Severity and Treatment Response

Although respiratory viruses are common triggers of asthma exacerbations, the influence of viral infection characteristics on exacerbation presentation and treatment response in the pediatric emergency department (ED) is unclear. To assess viral infection characteristics of children experiencing ED asthma exacerbations and to test their associations with severity and treatment response. This is a prospective study of children, aged 4 to 18 years, who received standard ED asthma exacerbation treatment with inhaled bronchodilators and systemic corticosteroids. Nasal swabs collected for viral metagenomic analyses determined virus presence, load, and species. Outcomes included exacerbation severity (Pediatric Asthma Severity [PAS] score, clinician impression, and vital signs) and treatment response (discharge home without needing additional asthma therapies). Of 107 children, 47% had moderate/severe exacerbations by PAS and 64% demonstrated treatment response. Viral metagenomic analysis on nasal swabs from 73 children detected virus in 86%, with 10 different species identified, primarily rhinovirus A (RV-A), RV-C, and enterovirus D68. Exacerbations involving RV-A were milder (odds ratio [OR]= 0.25; 95% confidence interval [CI]= 0.07-0.83) and tended to be more responsive to treatment than non-RV-A infections, whereas exacerbations involving enterovirus D68 were more severe (OR= 8.3; 95% CI= 1.3-164.7) and had no treatment response association. Viral load was not associated with treatment response but exhibited a strong linear relationship with heart rate (rpartial= 0.48), respiratory rate (rpartial= 0.25), and oxygen saturation (rpartial= -0.25), indicative of severity. The majority of ED asthma exacerbations are triggered by respiratory viruses. Viral species are associated with severity and treatment response, suggesting that early pathogen detection could inform ED treatment decisions. Additional studies are needed to identify differences in pathobiology underlying exacerbations triggered by different viral species, and how to effectively treat these heterogeneous exacerbations.

Neonatal presentations in the pediatric emergency department: A decade-long retrospective analysis

BackgroundThe global increase in neonatal visits to Pediatric Emergency Departments (PEDs) underscores the need to better understand the factors driving these visits and their implications. The often vague and nonspecific symptoms of neonates pose significant challenges for clinicians and caregivers in determining the appropriate level of care, impacting the frequency of return visits and overall effectiveness of discharge education. ObjectiveThis study aims to compile the most common chief complaints of neonates in the PED and analyze their association with admission rates and final ED diagnoses to inform educational interventions for caregivers and medical personnel. MethodsThis was a retrospective review of data from medical records from neonatal (≤30 days of life) presentations to the PED at a quaternary care medical center in Portland, Oregon, USA from January 2012 to December 2022. Results3175 patient encounters were identified, of which one-third (38 %) were admitted to the hospital. The most frequent 25 chief complaints are shown in Table 1. Certain complaints had higher admission rates than the average: temperature instability (71 % for “fever” and 89 % for “hypothermia”), breast concerns (68 %), abnormal lab results (63 %), “seizures” (53 %), and cardiac concerns (54 %). Notably, neonates presented on DOL 0 and DOL 1 had elevated admission rates of 77 % and 66 %, respectively. ConclusionThis study identified specific complaints that were most likely to result in hospital admissions and return visits to the ED. This can guide targeted educational interventions for caregivers and ED providers and refinement of triage protocols to ensure that neonates receive the most appropriate and efficient care.

Association between food insecurity and healthcare utilization among patients at a breast oncology center.

143 Background: A breast cancer (BC) diagnosis often creates or exacerbates financial stress. As a result, many patients with BC struggle with a lack of consistent access to nutritious food due to limited resources, a condition termed “food insecurity” (FI). We investigated the association between FI and healthcare utilization among breast oncology patients at our urban academic medical center. Methods: Screening for health-related social needs (HRSN) was conducted primarily through the electronic patient portal, at appointment registration for a breast oncology clinic visit. The 8-item HRSN survey included 2 questions on access to food resources and 1 question quantifying emergency department (ED) visits over the past year. Any level of food hardship or concern constituted a positive FI screen. We conducted a retrospective analysis among patients evaluated between 11/2/22 and 4/20/24. Clinical and demographic data were obtained from the electronic health record (EHR). We evaluated the association between FI and health care utilization measures (ED visits, inpatient admissions) with a Pearson's Chi-squared test and univariate logistic regression. Results: A total of 2820 patients were screened for HRSN and provided responses to at least 1 FI question, of which 19.7% (555) reported some level of FI. Food-insecure patients self-reported significantly higher rates of ED visits in the past 12 months compared to food-secure patients: 43.2% vs 22.6% reported at least 1 ED visit, respectively (p&lt;0.001), and 25.0% vs 8.45% reported multiple ED visits, respectively (p&lt;0.001). Overall, FI was associated with 2.5 times the odds of self-reporting at least 1 ED visit (univariate OR 2.47, p&lt;0.001). Similarly, on review of EHR data, 33.3% of food-insecure patients had at least 1 ED visit (vs 20.0% of food-secure patients, p&lt;0.001), and 6.13% had 3 or more ED visits (vs 2.83%, p&lt;0.001) during the study period. On univariate analysis, food-insecure patients had double the odds of having at least 1 ED visit documented in the EHR (univariate OR 2.00, p&lt;0.001). We examined reasons for ED presentations among 186 food-insecure patients with ED visits during the study period, and found that 23.8% had at least 1 cancer-related complaint (oncological treatment-related (16.8%) and/or BC symptom-related (8.6%)). The incidence of inpatient admissions during the study period was similar among food-insecure vs food-secure patients (19.8% vs 18.4%, p=0.467). Conclusions: In this analysis of FI and health care delivery measures, ED utilization was significantly higher among food-insecure patients. A quarter of food-insecure patients who presented to the ED had oncological complaints. FI may be a marker of unmet healthcare needs in patient with cancer, and targeted interventions focused on symptom monitoring and management are warranted to optimize healthcare utilization.

Approach to Acute Dizziness/Vertigo in the Emergency Department: Selected Controversies Regarding Specialty Consultation.

Acute dizziness and vertigo are common emergency department presentations (≈4% of annual visits) and sometimes, a life-threatening diagnosis like stroke is missed. Recent literature reviews the challenges in evaluation of these symptoms and offers guidelines for diagnostic approaches. Strong evidence indicates that when well-trained providers perform a high-quality bedside neurovestibular examination, accurate diagnosis of peripheral vestibular disorders and stroke increases. However, it is less clear who can and should be performing these assessments on a routine basis. This article offers a focused debate for and against routine specialty consultation for patients with acute dizziness or vertigo in the emergency department as well as a potential path forward utilizing new portable technologies to quantify eye movements.

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.

The Effectiveness of a Community Specialist Team for Older Persons in Preventing Emergency Department Attendances 30 and 90 Days Post-Intervention

Abstract Background Population ageing is prevalent throughout Ireland and its impact is evident particularly in acute hospitals with long Patient Experience Times (PETs) in the emergency department. A Community Specialist Team for Older Persons (CSTOP) was established in our area in 2018 with expansion under Sláintecare in 2022. The main goal is to improve access in the community to age attuned services, and thus prevent Emergency Department (ED) presentations and admissions and improving health outcomes for older people. The team provides a comprehensive geriatric assessment and resultant interventions required for each patient. The cohort of patients includes (Frail Intervention Team) FIT referrals from the ED, Geriatrician referrals from Outpatient clinics and GP referrals. Many of these patients have either presented to the Emergency Department or are at risk of same. Methods Data for all CSTOP patients is recorded including medical record numbers. All medical records for patient admitted in 2023 were analysed using the integrated patient management system (IPIMS) in our local hospital. ED presentations and admissions were reviewed at 30 and 90 days post intervention. Results 232 referrals were received in 2023. 42 (18%) had an ED presentation 30 days post discharge and 48 (21%) had a presentation 90 days post discharge. 11 RIPs. Conclusion This study shows the effectiveness of the CSTOP team at preventing ED presentations and resultant admissions. The number of bed days is estimated at 2000. One limitation to our study is data could only be analysed from our hospital system, patients could attend other public or private hospitals during the follow up period. Our results are found to be in keeping with reviews by similar services. Our team provide a rapid access interdisciplinary assessment and intervention to people who may otherwise experience fragmented care within primary care services.

Safer Care for Older People in the Emergency Department

Abstract Background The number of over 75-year-old patients (O75YOs) presenting to our Emergency Department (ED) has increased by 35% since 2020 and continues to rise. It is well documented that older people present more frequently to EDs with a higher level of illness severity, a higher rate of admission or re-attendance and are at a greater risk of adverse outcomes such as falls, delirium, prolonged ED and/or hospital stay and ultimately mortality (Tan et al. 2012). We developed a safety huddle to identify and reduce risks to older people in our ED with a view to improving their outcomes. Methods Our 10-minute huddle took place each day at 3pm (peak occupation time of O75YOs). An ED physician, nurse, AHP and Geriatrician/Registrar were required to attend. The huddle script was developed based on feedback from clinicians and a literature review on risks associated with an ED presentation in older adults. The script focused on recording resourcing issues critical to patient care. The primary risk factors recorded included falls risk, delirium, administration of time critical medications and PET times. Following the huddle, HCPs involved in the patient’s care were updated by the relevant member of the MDT in attendance to ensure agreed interventions were completed/in place. Results We observed a decrease in the number of falls from 2 to 0. Delirium screening improved from 0% to 26%. Identification and administration of time critical medications improved from 0% to 78%. PET times increased slightly (2%), however admission rates decreased indicating value added to the patients’ journey. Conclusion Whilst we acknowledge there is still room for improvement, these results will clearly have a positive impact on patient outcomes.

Effectiveness of Community-Based Multidisciplinary Integrated Care for Older Adults with General Practitioner Involvement: A Systematic Review and Meta-Analysis

Abstract Background Changing demographics has led to healthcare systems reorientating healthcare delivery towards the community setting and implementing integrated models of care worldwide. A knowledge gap exists with regards to what elements of integrated care facilitate effective age-attuned healthcare delivery. This systematic review examines the effectiveness of community-based multidisciplinary integrated care strategies with General Practitioner (GP) participation for community-dwelling older adults and describes the level of care integration in each study. Methods PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE were systematically searched in April 2023. Randomised controlled trials (RCTs) or cluster RCTs that focused on interventions for community-dwelling older adults delivered by health and social care professionals with GPs were included. Two reviewers independently conducted the risk of bias assessment, applied the GRADE tool to quantify the certainty of evidence and used the Rainbow Model of Integrated Care taxonomy to describe the elements of integrated care used within studies. The primary outcome was functional status. Meta-analyses were performed using Review Manager 5.4. Results Twelve trials (14 reports) recruiting 8069 participants across 8 countries were included. Community-based multidisciplinary team (MDT) integrated care demonstrated significant improvements in functional status (standardised mean difference (SMD) 0.21, 95% confidence interval (CI) 0.05-0.37; low certainty evidence), hospitalisation (risk ratio (RR) 0.77, 95% CI 0.63-0.95; very low certainty evidence) and participant satisfaction with care (SMD 0.46, 95%c CI 0.15-0.76; low certainty evidence) from 12-36 months. No statistically significant effects favouring community-based MDT interventions for functional status at 6-month follow-up, Emergency Department presentation, mortality, health-related quality of life, or nursing home admission were established. Conclusion Community-based MDT integrated care with GP participation improves clinical and process outcomes for community-dwelling older adults. Future research should focus on models of integrated care that respond to the needs and preferences of older adults.

As Fit as a Fiddle

Abstract Background The EDITH (emergency department in the home) team is an alternative pathway for older adults requiring emergency care. The team consists of an occupational therapist (OT) and a doctor who provide specialized geriatric care in patients' homes thus negating the need for an emergency department (ED) presentation. The patients' profile is typically frail older adults however this service can be accessed by any person over 65 years within the catchment. Methods Clinical frailty scales (CFS) are routinely completed as part of the OT assessment process. A review of the OT logbooks and electronic healthcare records was completed over an 18-month period. The average CFS was 6 however 11 patients with a CFS of 1 or 2 were identified. The health care records was analysed to identify similarities in this subset patient population group. Results It was found that none of these patients had formal supports, and none were living in residential care. The age range was 65 to 90 years old. None of these patients required an onwards referral to community services or provision of OT equipment. Presenting complaint breakdown: explained falls (2), DVT (2), Blood pressure issues (2), pain (2), catheter (1), covid (1), INR problems (1). At 3 months post EDITH review it was found that no patients had a re attendance to ED. Conclusion Patients with a low level of clinical frailty make up a very small sub set of the general EDITH patient population. These patients appear to be living independently within the community and do not require extensive OT input. Their presenting complaints appear to be predominately isolated medical events as opposed to chronic medical issues.