Emergency Department Presentation Research Articles

Factors Associated With Early Computed Tomography Imaging in Children Hospitalized With Severe Orbital Infections.

We identified factors associated with computed tomographic (CT) imaging within 24 hours of emergency department (ED) presentation in hospitalized children with severe orbital infections. A multicenter retrospective cohort study was conducted that included children aged 2 months to 18years between 2009 and 2018 who were admitted to the hospital with severe orbital infections, including periorbital and orbital cellulitis. Multivariable modified Poisson regression was used to identify possible factors associated with receiving a CT scan within 24 hours of ED presentation. Of 1144 children, 494 (43.2%) received a CT scan within 24 hours of ED presentation. Factors associated with receiving a CT scan within 24 hours included sex (male; adjusted relative risk [aRR], 1.18; 95% CI, 1.04-1.33), hospitalized at a children's hospital (aRR, 1.80; 95% CI, 1.32-2.45), consulted by both ophthalmology and otolaryngology (aRR, 3.12; 95% CI, 2.35-4.13) or either ophthalmology (aRR, 2.19; 95% CI, 1.66-2.90) or otolaryngology (aRR, 2.66; 95% CI, 1.84-3.86), and had proptosis (aRR, 1.39; 95% CI, 1.24-1.57) or eye swollen shut (aRR, 1.27; 95% CI, 1.13-1.43) as clinical signs upon ED presentation. Children aged younger than 5years were less likely to receive early CT imaging (aRR, 0.63; 95% CI, 0.53-0.74). There were no associations between time of ED triage, temperature greater than 38 °C, or inflammatory markers with early CT imaging. Although several patient and hospital factors associated with early CT imaging decisions in children with severe orbital infections are associated with more severe infections, newly identified risk factors, such as inflammatory markers, were not. These findings will help better the understanding of clinical management and indications for CT imaging.

Health service access and quality of care provided by the Western NSW Local Health District Virtual Rural Generalist Service: a retrospective analysis of linked administrative data.

To evaluate the quantity and quality of medical care provided by the Western NSW Local Health District Virtual Rural Generalist Service (VRGS). Retrospective cohort study; analysis of emergency department and administrative hospital data. Twenty-nine rural or remote hospitals in the Western NSW Local Health District at which the VRGS was providing medical care in the emergency department (ED) and/or inpatient setting. The VRGS was providing predominantly virtual medical support when local doctors needed relief or were unavailable, typically for lower acuity ED presentations and scheduled inpatient ward rounds. All patients who presented or were admitted to a Western NSW Local Health District hospital serviced by the VRGS between 1 July 2021 and 30 June 2022. Treatment completions, transfers, ED departure within 4 hours, length of stay, and hospital mortality. During 2021-22, 34% of ED presentations (13 660/39 701) and 40% of admissions (2531/6328) involved VRGS care. For ED presentations, after adjusting for socio-demographic and clinical factors, patients attended by VRGS doctors had higher odds of not waiting (adjusted odds ratio [aOR], 3.69; 95% CI, 2.79-4.89), lower odds of transfer to another hospital (aOR, 0.66; 95% CI, 0.60-0.72) and slightly lower odds of ED departure within 4 hours (aOR, 0.92; 95% CI, 0.86-0.98) when compared with patients not attended by VRGS doctors (ie, those provided usual care). For admissions, after adjusting for socio-demographic and clinical factors, inpatients attended exclusively by VRGS doctors had higher odds of discharging at their own risk (3.33; 95% CI, 1.98-5.61) and lower odds of being a long stay outlier (aOR, 0.51; 95% CI, 0.35-0.74) when compared with inpatients not attended by VRGS doctors. The odds of inpatient mortality were equivalent when comparing VRGS and non-VRGS care (aOR, 0.78; 95% CI, 0.48-1.28) and when comparing combined (VRGS and non-VRGS) and non-VRGS care (aOR 1.21; 95% CI, 0.91-1.61). In the current environment of rural medical workforce shortages, the VRGS achieved similar outcomes on routinely collected measures of quality of care. It is demonstrably an option for complementing and enhancing the delivery of medical care in rural and remote communities with limited or no local medical services.

An economic evaluation of the Virtual Rural Generalist Service versus usual care in Western NSW Local Health District.

Evaluate the cost-effectiveness of the Virtual Rural Generalist Service (VRGS) model of care. A cost-consequence analysis of the VRGS model of care compared with usual care (treatment by local or locum [non-VRGS] doctors) from the perspective of the health care funder in 2022 prices. Twenty-nine rural and remote hospitals in the Western NSW Local Health District where the VRGS has been in operation (VRGS sites). Patients of any age who presented to an emergency department (ED) or were admitted to hospital at VRGS sites over the pre-VRGS period (1 February 2019 to 31 January 2020) or the post-VRGS period (1 July 2021 to 30 June 2022). The VRGS model of care, which provides 24-hour 7-days-a-week rural generalist doctors, both virtually and in person, to small rural and remote hospitals, predominantly for lower acuity ED presentations, daily ward rounds for inpatients admitted by a VRGS medical officer, and ad hoc inpatient medical reviews when local doctors need support or are unavailable. Incremental cost per incremental quality-of-care outcome, maintenance of health service activity levels, workforce sustainability (measured by changes in locum shifts), and service acceptability (as determined by thematic analysis of interviews). The cost per standard unit of health care (national weighted activity unit) was lower for the VRGS ($1047) than for usual care ($1753). VRGS doctors dealt with ED presentations of similar complexity to non-VRGS doctors, and admissions of significantly lower (40%) complexity. Health service activity remained stable from the pre-VRGS period to the post-VRGS period, only declining by 4% in the post-VRGS period, which was during the coronavirus disease 2019 pandemic. Locum shifts decreased from 1456 days in the pre-VRGS period to 609 days in the post-VRGS period, improving the sustainability of the workforce. Local doctors and managers found the VRGS to be acceptable, but thought it could be enhanced with additional investment in nursing and technical staff. Our economic evaluation of the VRGS showed that it provided lower cost care and equivalent quality-of-care outcomes when compared with usual care for ED presentations of the same complexity, and supported local clinical staff to maintain activity levels despite a pandemic. With additional investment in data capture and in nursing and technical staff to support the service, the VRGS has promise as a flexible service that can help sustain access to quality medical care in rural and remote communities.

Acute Aortic Dissection Complicating Emergency Coronary Intervention for Hyperacute Stent Thrombosis

Introduction: Iatrogenic acute aortic dissection resulting from coronary interventions can have fatal consequences. Although it is an uncommon complication during percutaneous coronary interventions (PCI), it can arise from various factors. Our case report aims to address this rare presentation further, seeking to enhance preprocedural planning which can result in better outcomes. Case Report: We describe an intriguing case of an elderly female patient with multiple cardiovascular risk factors who came to our emergency department presenting with chest pain. Her Electrocardiogram revealed an inferior ST-elevation myocardial infarction (STEMI) for which she underwent successful primary PCI of the right coronary artery (RCA). Four days later, she had an infero-posterior STEMI, which necessitated immediate coronary angiography. Angiography revealed thrombosis of the stent placed earlier in the RCA. On attempting recanalization of the vessel, an acute aortic dissection was identified and was successfully managed by ostial stenting. Follow-up imaging showed no residual dissection, and the patient was found to be comfortable and stable post-procedure. Conclusion: We recommend optimizing blood pressure and performing rapid ostial stenting in these cases, irrespective of the dissection’s origin. This will facilitate effective sealing of the entry site and prevent further progression of the dissection. Our report highlights the favorable results achieved with immediate ostial stenting while discussing the conservative approach to managing such cases.

Clinical and cost-effectiveness of earlier discharge from acute hospital after total joint arthroplasty.

Reducing length of stay has been proposed as a key component of policies that aim to meet demand and minimize costs associated with total joint arthroplasty. However, few studies explore shifting of healthcare utilization when length of stay is shortened. This retrospective cohort study examined patients undergoing primary, total hip and knee arthroplasty for osteoarthritis to simulate a policy-level institutional reduction in acute hospital stay by 1 day. Costs, quality of life, and rates of complications, readmission and discharge to inpatient rehabilitation were compared in patients with a three- and four-day length of acute stay. Balance was achieved using overlap-propensity weighting. In total, 2023 patients were included. Earlier discharge from acute hospital was not associated with a change in odds of 90-day complications (OR: 0.85 [95% CI, 0.58 to 1.27]; P = 0.447), readmissions (OR: 1.11 [95% CI, 0.67 to 1.82]; P = 0.691), and emergency department presentations (OR: 1.07 [95% CI, 0.66 to 1.73]; P = 0.774). Earlier discharge from acute hospital was associated with an increase in odds of discharge to inpatient rehabilitation (OR: 2.16 [95% CI, 1.45 to 3.20]; P < 0.001). No significant differences in costs and quality adjusted life years were observed at one-year. Cost savings during index admission were shifted onto increased costs associated with inpatient rehabilitation. Earlier discharge was not associated with changes in 90-day complications, readmission, or ED presentations. However, an increase in utilization of inpatient rehabilitation was observed, offsetting early cost savings. Patients who were discharged from acute care on day three had no difference in costs compared to those discharged on day four.

An analysis of e-scooter-related trauma in Ireland: an update.

Electronic (E)-scooters have become increasingly common in Ireland. Our group was the first to publish an analysis of injuries related to these devices in Ireland in 2021. Since then, the use of e-scooters has increased significantly. The primary aim of this study was to re-analyse the trend in scooter-related trauma 4 years later. We conducted a retrospective analysis over the same time period as our previous study (13 months). Seventy-six patients with e-scooter-related trauma in our emergency department (ED) were identified between June 2023 and July 2024. Medical records and patient imaging were reviewed. Injury severity score (ISS) was calculated, and results were compared to our previous study. There was an increase from 22 to 76 patients presenting to our ED with an e-scooter-related injury over a 13-month period. The number of patients presenting with fractures has risen from 15 to 34 (45%). Twenty-four per cent of ED attendees required hospital admission, and 13 patients underwent surgical intervention. The average ISS was 4.3, and helmet use has decreased significantly from 40% to 8%. E-scooters remain to be a key contributor to emergency department presentations and complex orthopaedic injuries. The majority of patients require radiological investigation and specialist follow-up, with many needing surgical fixation. The effects of such injuries can have severe long-term consequences for patients and place financial constraints on our health system. With the rollout of e-scooter rental schemes and infrequent helmet use, one can expect the resulting trauma will continue to rise.

Pediatric Triage Accuracy in Pediatric and General Emergency Departments.

Accurate triage at the time of emergency department (ED) presentation is critical for timely acuity assessment and anticipating resource requirements. Commonly, triage is conducted using the Emergency Severity Index (ESI); however, the accuracy of this approach for children in general EDs is uncertain. The purpose of this study was to quantify pediatric triage accuracy in a national sample of ED visits and evaluate whether presentation to a pediatric vs general ED is associated with mistriage. This was a cross-sectional study of the 2017-2021 National Hospital Ambulatory Medical Care Survey of pediatric (aged <18years) ED visits with an ESI score from 3 to 5. The outcome was mistriage (resource utilization discordant with ESI prediction). Standardized ESI definitions were applied to count resources. We used multivariable logistic regression to evaluate whether presentation to a pediatric or general ED was associated with triage accuracy. Of 149 million visits, mistriage occurred in 53.7% of ESI 3, 57.7% of ESI 4, and 22.9% of ESI 5 visits. Children in general EDs were more likely to be mistriaged than children in pediatric EDs (adjusted odds ratio [OR], 1.29; 95% CI, 1.11-1.50). Young age was associated with mistriage (aged <1year vs aged 13-17: adjusted OR [95% CI], 2.42 [2.00-2.94], 1-5years: 1.79 [1.53-2.10], 6-12years: 1.38 [1.16-1.64]). Mistriage was common among children with an initial ESI of 3 to 5 and more common among children visiting general EDs. Our findings highlight the need for improved resource prediction at the time of triage.

Self-harm-related mental health presentations to emergency departments by children and young people from culturally and linguistically diverse groups in South Western Sydney.

Rates of self-harm among children and young people (CYP) have been on the rise, presenting major public health concerns in Australia and worldwide. However, there is a scarcity of evidence relating to self-harm among CYP from culturally and linguistically diverse (CALD) backgrounds. To analyse the relationship between self-harm-related mental health presentations of CYP to emergency departments and CALD status in South Western Sydney (SWS), Australia. We analysed electronic medical records of mental health-related emergency department presentations by CYP aged between 10 and up to 18 years in six public hospitals in the SWS region from January 2016 to March 2022. A multilevel logistic regression model was used on these data to assess the association between self-harm-related presentations and CALD status while adjusting for covariates and individual-level clustering. Self-harm accounted for 2457 (31.5%) of the 7789 mental health-related emergency department presentations by CYP; CYP from a CALD background accounted for only 8% (n = 198) of the self-harm-related presentations. CYP from the lowest two most socioeconomic disadvantaged areas made 63% (n = 1544) of the total self-harm-related presentations. Findings of the regression models showed that CYP from a CALD background (compared with those from non-CALD backgrounds) had 19% lower odds of self-harm (adjusted odds ratio 0.81, 95% CI 0.66-0.99). Findings of this study provide insights into the self-harm-related mental health presentations and other critical clinical features related to CYP from CALD backgrounds that could better inform health service planning and policy to manage self-harm presentations and mental health problems among CYP.

Strategies to reduce 28-day mortality in adult patients with bacteremia in the emergency department

BackgroundBacteremia, a common emergency department presentation, has a high burden of mortality, cost and morbidity. We aimed to identify areas for potential improvement in emergency department bacteremia management.MethodsThis retrospective cohort study included adults with bacteremia in an emergency department in 2019 and 2022. The primary outcome was 28-day mortality. Descriptive analyses evaluated demographics, comorbidities and clinical characteristics. Univariate and multivariate analyses identified mortality predictors.ResultsOverall, 433 patients were included [217 males (50.1%), mean ± SD age: 74.1 ± 15.2 years]. The 28-day mortality rate was 15.2% (n = 66). In univariate analysis, age ≥ 70 years, arrival by ambulance, arrhythmia, congestive heart failure, recent steroid use, hypotension (< 90/60 mmHg), mechanical ventilation, cardiac arrest, intensive care unit (ICU) admission, intravenous antibiotics, pneumonia as bacteremia source, non-urinary tract infections, no infectious disease consultation, no antibiotic adjustment and no control blood cultures were significantly associated with 28-day mortality (p < 0.05). Malignancy showed a statistical trend (0.05 < p < 0.15). The above-stated sixteen variables, identified in univariate analysis, were assessed via multivariate analysis. Primarily, clinical relevance and, secondarily, statistical significance were used for multivariate model creation to prioritize pertinent variables. Five risk factors, significantly associated with mortality (p < 0.05), were included in the model: ICU admission [adjusted OR (95% CI): 6.03 (3.08–11.81)], pneumonia as bacteremia source [4.94 (2.62–9.32)], age ≥ 70 [3.16 (1.39–7.17)], hypotension [2.12 (1.02–4.40)], and no infectious disease consultation [2.02 (1.08–3.78)]). Surprisingly, initial antibiotic administration within 6 h, inappropriate initial antibiotic regimen and type of bacteria (Gram-negative, Gram-positive) were non-significant (p > 0.05).ConclusionsWe identified significant mortality predictors among emergency department patients presenting with bacteremia. Referral to an infectious disease physician is the only modifiable strategy to decrease 28-day mortality with long-term effect and should be prioritized.

Understanding Trends in Pediatric Drowning Injuries in North Carolina.

Drowning is a leading cause of injury-related death in the pediatric and adolescent population. This epidemiologic study describes the trends in emergency department (ED) visits for pediatric drowning injury in North Carolina and the impact of the coronavirus disease 2019 (COVID-19) pandemic on incidence rate. Data were obtained using the North Carolina Disease Event Tracking and Epidemiologic Collection Tool, a public health surveillance system, to identify ED visits for drowning injury from 2016 to 2022. We performed a chart review on a subset of patients to further characterize injury. A total of 1285 ED encounters were identified. In North Carolina, the incidence rate of pediatric drowning has been decreasing, abruptly in 2019 and again in 2020. The postpandemic rate continued in the same downward trend, suggesting that the COVID-19 pandemic did not affect the overall statewide incidence rate of pediatric drowning (P = 0.14). The age distribution of children treated in the ED for drowning injury in North Carolina changed following the pandemic. This study is limited by the fortunate rarity of pediatric drowning events. Injuries may be underreported because these are only ED presentations. This study relied on provider documentation in electronic health records. The definition of postpandemic is not well defined, and sequelae of the COVID-19 pandemic may not yet be fully appreciated. The incidence of North Carolina ED encounters for drowning injury in the pediatric population has decreased, and the COVID-19 pandemic had a noticeable, although not statistically significant, effect.

Implementation of a Patient-Specific Opioid Taper Calculator for Total Hip and Knee Arthroplasty: A Pre-Post Study

BackgroundGiven the association between high opioid use and postoperative complications after total joint arthroplasty, it is important to prescribe opioids responsibly in the postoperative period. While many pain regimen protocols exist to try and limit opioid use, an optimal approach to narcotic prescription for arthroplasty patients is yet to be established. This study evaluated the effects of using an individualized opioid taper calculator for patients undergoing elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that using the calculator would lead to a decrease in the amount and variability of opioids prescribed postoperatively. MethodsAll primary THAs (117 pre- and 105 post-calculator) and TKAs (172 pre- and 139 post-calculator) meeting study inclusion and exclusion criteria were reviewed at a single academic hospital from January 2016 to December 2018 (pre-calculator) and January 2020 to December 2022 (post-calculator). The primary outcome measure was the quantity of opioids prescribed at discharge in morphine milligram equivalents (MME) between the two groups. Secondary measures included opioid refills, visual analog scale (VAS) pain scores, and emergency department (ED) presentations or clinic calls due to pain. Statistical significance was defined as P < 0.05. ResultsImplementation of the opioid taper calculator resulted in a 40% decrease in the median MME prescribed at discharge for both THA (450 versus 270; P < 0.0001) and TKA (450 versus 270; P < 0.0001) patients, respectively. There was no significant difference within the THA or TKA cohorts when comparing VAS pain scores (THA, three versus four; P = 0.47; TKA; five versus six, P = 0.26), and no increase in percentage of patients who had ED visits (THA, 5.98 versus 0.95%; P = 0.069; TKA, 6.40 versus 11.5%; P = 0.155) or calls to the clinic for pain (THA, 17.1 versus 24.8%; P = 0.186; TKA, 36.6 versus 37.4%; P = 0.906) between the pre-calculator and post-calculator groups. ConclusionsOur findings support the use of a patient-specific opioid taper calculator to decrease the volume and variability of narcotics prescribed postoperatively for THA and TKA pain management. Our findings confirmed the general applicability and effectiveness of the opioid taper calculator outside of its institution of origin.

A Prediction Model to Identify Clinically Relevant Medication Discrepancies at the Emergency Department (MED-REC Predictor): Development and Validation Study.

Many patients do not receive a comprehensive medication reconciliation, mostly owing to limited resources. We hence need an approach to identify those patients at the emergency department (ED) who are at increased risk for clinically relevant discrepancies. The aim of our study was to develop and externally validate a prediction model to identify patients at risk for at least 1 clinically relevant medication discrepancy upon ED presentation. A prospective, multicenter, observational study was conducted at the University Hospitals Leuven and General Hospital Sint-Jan Brugge-Oostende AV, Belgium. Medication histories were obtained from patients admitted to the ED between November 2017 and May 2022, and clinically relevant medication discrepancies were identified. Three distinct datasets were created for model development, temporal external validation, and geographic external validation. Multivariable logistic regression with backward stepwise selection was used to select the final model. The presence of at least 1 clinically relevant discrepancy was the dependent variable. The model was evaluated by measuring calibration, discrimination, classification, and net benefit. We included 824, 350, and 119 patients in the development, temporal validation, and geographic validation dataset, respectively. The final model contained 8 predictors, for example, age, residence before admission, number of drugs, and number of drugs of certain drug classes based on Anatomical Therapeutic Chemical coding. Temporal validation showed excellent calibration with a slope of 1.09 and an intercept of 0.18. Discrimination was moderate with a c-index (concordance index) of 0.67 (95% CI 0.61-0.73). In the geographic validation dataset, the calibration slope and intercept were 1.35 and 0.83, respectively, and the c-index was 0.68 (95% CI 0.58-0.78). The model showed net benefit over a range of clinically reasonable threshold probabilities and outperformed other selection criteria. Our software-implemented prediction model shows moderate performance, outperforming random or typical selection criteria for medication reconciliation. Depending on available resources, the probability threshold can be customized to increase either the specificity or the sensitivity of the model.

Benefit of Expedited Time to Hip Fracture Surgery Differs Based on Patient Risk Profile.

To identify which hip fracture patients benefit the most from operative repair within 24 hours of Emergency Department (ED) presentation based on patient risk stratification. Design: Retrospective Cohort. Academic Medical Center. Patients operatively treated for an AO/OTA 31A, 31B, or 32A hip fracture. Each patient was placed into an "individualized risk quartile" (IRQ) using a validated risk stratification tool (The Score for Trauma Triage in the Geriatric and Middle-Aged [STTGMA], a tool proven to predict inpatient mortality in trauma patients). Patients were risk stratified into minimal-, low-, moderate-, and high-risk IRQ's. In each cohort, patients were separated into three groups based on their time from ED arrival to surgery (< 24 hours, > 24 hours and < 48 hours, and > 48 hours). Each of these 12 groups was analyzed for complications (minor inpatient complications included acute kidney injury, urinary tract infection, decubitus ulcer, and acute blood loss anemia, while major inpatient complications included sepsis or septic shock, pneumonia, acute respiratory failure, stroke, myocardial infarction, cardiac arrest, and deep vein thrombosis or pulmonary embolism), mortality rates, and hospital quality measures (length of stay and readmission rates). The results were compared across cohorts. A total of 2472 patients were identified: the mean age of the cohort was 80.6 ± 10.3 and was predominantly female (69%) and white (71%). The data demonstrated improved outcomes (complications, mortality rates, hospital quality measures) across all patients (non-risk stratified) for surgery within 24 hours compared to surgery between 24 hours and 48 hours and surgery greater than 48 hours (all outcomes p<0.050). However, these effects were not evenly distributed among the IRQ's. In the IRQ4 cohort, major complication rates progressed from 20% to 25% to 34% as a function of time to surgery (p=0.007). IRQ1 did not demonstrate similar results (p=0.756), with the rates essentially static across surgery time points (3% to 2% to 4%). A similar trend was seen when analyzing mortality at 1-year for highest risk patients, with similar 1-year mortality rates across operating room windows of IRQs 1-3 (IRQ1: p=0.061, IRQ2: p=0.259, IRQ3: p=0.524), but increased in IRQ4 with increasing time to surgery (21% vs 33% vs 33%, p=0.006). This study demonstrates a differential impact of expedited time to surgery on patients when stratified by risk profile. The lowest risk hip fracture patients do not fare worse if operated on within 48 hours as compared to 24 hours. III.

Buprenorphine initiation and rates of associated precipitated withdrawal in patients with fentanyl use in an urban emergency department

BackgroundFentanyl use has been linked with an increasing number of opioid-related deaths. The emergency department (ED) is a critical contact point for patients with opioid use disorder (OUD) to access basic healthcare. Little information is known about buprenorphine precipitated opioid withdrawal (BPOW). This study sought to examine the rates of BPOW in patients who used fentanyl and received buprenorphine in the ED. MethodsA retrospective cohort study was conducted in a single emergency department in an urban city and included patients who reported use of fentanyl and who received buprenorphine for opioid withdrawal. The primary outcome was occurrence of BPOW, in which we assessed for interrater reliability between data abstractors. Data extraction included patients' demographic characteristics, date of service, length of stay, Clinical Opiate Withdrawal Scale (COWS) score assessments, dosages of administered buprenorphine, occurrence of BPOW, and ED disposition. ResultsOver the course of 28 months, buprenorphine was administered 113 patients (12.5 %) who reported using fentanyl prior to their ED presentation. The majority of patients identified as White (49 %), and most patients presented with a chief complaint other than specific opioid related concerns. Fifty-one patients (45 %) had an initial COWS score documented, with a median score of 11. Three patients (2.6 %) had BPOW, two of whom required intensive care unit (ICU) admission. ConclusionsWe demonstrate that the prevalence of BPOW is low in a cohort of patients who use fentanyl. When precipitated withdrawal does occur, however, it can be severe and require intensive treatment, ICU admission, and prolonged hospital stay.

Low-acuity emergency department presentation characteristics and their association with Medicare-subsidised general practitioner services across New South Wales: A data linkage study.

Identify clinical and demographic characteristics of low-acuity presentations (LAPs) to the ED and analyse correlations between population rates of LAPs to ED and rates of Medicare-subsidised general practitioner (GP) services across statistical areas. Retrospective data linkage study using state-wide ED data and publicly available data on GP services per population by statistical area. We performed multilevel logistic regression to determine predictors of LAP at an individual level after adjusting for remoteness categories and performed correlations between rates of LAP and GP services per population across statistical areas in New South Wales, Australia. The primary outcome was the rate of LAPs to ED, LAPs being defined as patients who self-presented to ED, assigned an Australasian Triage Score of 4 or 5 and subsequently discharged from ED. There were 2.9 million ED presentations in 2021, of which 39.9% presentations were classified as LAP. LAPs were associated with younger age, routine care, eyes, ear, nose and throat and musculoskeletal presentations. The rate of LAPs was higher in non-metropolitan areas. Additionally, 85% of LAPs were seen and discharged from ED within 4 h. There was an inverse correlation between the rate of Medicare-subsidised GP services and the rate of total ED or LAPs in non-metropolitan areas (ρ = -0.47, ρ = -056 and P = 0.012, P = 0.001, respectively). In metropolitan areas, correlations were either positive for all ED presentations (ρ = +0.41, P = 0.007) or not significant for LAPs (ρ = +0.18, P = 0.57). A relationship between LAPs to ED and Medicare-subsidised GP episodes of care exists for non-metropolitan but not metropolitan areas.

Does time to operating room affect outcomes after pediatric blunt hollow viscus injury? A Trauma Quality Improvement Program analysis.

Blunt hollow viscus injuries (HVIs) are relatively rare and difficult to diagnose. Whether a delay in operative intervention impacts outcomes for pediatric patients with blunt HVI has not been investigated via analysis of multicenter databases. We queried the Trauma Quality Improvement Program database from 2016 to 2020 for patients younger than 18 years who underwent an operation of the stomach, small intestine, large intestine, or rectum within 72 hours of emergency department arrival after blunt injury. We excluded patients with solid organ injury and additional extra-intestinal abdominal or thoracic operations. Patients were categorized by the time from emergency department presentation to operating room arrival: 1 to 5, 5 to 12, 12 to 24, and 24 to 72 hours. We analyzed baseline characteristics and outcomes between groups. We identified 1,700 patients, including 147 (9%) who were operated on >24 hours after arrival. Patients with delayed operations demonstrated higher Injury Severity Scores and higher Abbreviated Injury Scale scores for the head, face, and upper extremities and were more likely to require an orthopedic operation. Patients who received a delayed operation were less likely to have full-thickness injury noted in the operating room and demonstrated longer hospital and intensive care unit stays. However, there was no difference in superficial surgical site infection (SSI), deep SSI, organ space SSI, severe sepsis, or mortality between groups. Diagnosis and operative intervention for blunt HVI may be delayed in the presence of distracting injuries and in the absence of full-thickness perforation. While these patients typically have a more severe injury profile and require longer hospital stays, they do not appear to have increased rates of SSI, sepsis, or mortality. Therapeutic/Care Management; Level IV.

Urinary Retention After GreenLight Laser Photoselective Vaporization of the Prostate (GLL.PVP) Surgery for Benign Prostatic Hyperplasia (BPH): A 3-6 Month Retrospective Follow-Up Study.

Objective Our study was designed to evaluate the postoperative urinary retention (UR) and success rate of the GreenLight Laser (Boston Scientific, Marlborough, MA, USA) photoselective vaporization of the prostate (GLL.PVP) procedure for Benign Prostatic Hyperplasia (BPH) patients, both with and without high-risk factors. Methodology We conducted a retrospective follow-up study of postoperative patients who underwent GLL.PVP for BPH. We collected data from clinical health records, including notes from the lower urinary tract symptoms (LUTS) clinic, trial without catheter (TWOC) clinic, and emergency department presentations with UR. The analysis examined several parameters, including the patient's age, high-risk factors, prostate volume, and both preoperative and postoperative objective voiding parameters. These voiding parameters included post-void residual (PVR) and maximum flow rate (Qmax). Additionally, the analysis looked into whether the patient had a catheter or experienced urinary retention prior to the surgery. Results A total of 50 GreenLight Laser PVP surgeries were performed over a 14-month period from May 2023 to July 2024 at West Middlesex University Hospital in London. Most of the patients were between the ages of 60 and 80. Prior to the surgery, data indicated that 17 patients (34%) were using long-term catheters, whereas 33 patients (66%) were not. Additionally, 25 patients (50%) were identified as having high-risk factors, which included being on anticoagulation therapy, a history of urinary retention, and a prostate volume exceeding 100 cc.Notably, the patient without h/o urinary retention had an average preoperative PVR of 150 mL and an averageQmaxof 7 mL/second In our 3-6 month retrospective postoperative follow-up study, we found that eight cases (16%) developed urinary retention, while 42 cases (84%) did not, with an average PVR volume of 105 mL and an average Qmax of 13.5 mL/second. In patients with preoperative urinary retention, 13 cases (76%) did not develop UR postoperatively whereas four cases (24%) developed. Conclusion Our study conclusively found that 42 cases (84%) of patients did not experience urinary retention (UR) in the follow-up after undergoing the GLL PVP operation, irrespective of any history of urinary retention or other high-risk factors. This unequivocally demonstrates the operation's efficacy. Furthermore, our findings revealed that three-quarters of patients with a preoperative history of urinary retention also did not develop UR post-surgery. The GLL.PVP procedure is safe and effective, leading to rapid improvements in voiding parameters.

Evaluation of a youth-focused suicide prevention HOPE aftercare service: protocol for a non-randomized hybrid effectiveness-implementation type I design

BackgroundSuicide is the fourth leading cause of death among young people aged 15–29 worldwide. Young people often present to emergency departments (EDs) with self-harm and suicide-related behaviors. The period following discharge from the ED is recognized as one of elevated risk for both repeated self-harm and suicide. During this critical time, suicide prevention aftercare services are recommended. Despite their increased popularity, evidence demonstrating the effectiveness of these models is very limited.MethodsUsing a hybrid effectiveness-implementation type I design, this evaluation will assess the effectiveness and implementation of a suicide prevention aftercare (Hospital Outreach Post-suicidal Engagement; HOPE) service designed to reduce risk of self-harm and suicide in young people aged 12–25 who are referred to the service following an ED presentation for self-harm or suicide attempt. Two complementing theoretical frameworks will guide this evaluation, specifically the design, data collection, analysis, and interpretation of results. The RE-AIM evaluation framework will be used to assess Reach, Effectiveness (including cost-effectiveness), Adoption, Implementation and Maintenance of the HOPE aftercare service. The PRISM implementation framework will be used to assess multi-level contextual factors hypothesized to affect the RE-AIM outcomes. Several data sources will be used to assess the changes in primary and secondary outcomes from baseline to post–intervention, and at follow-up, including user and provider self-report surveys, semi-structured interviews, and routinely collected hospital data. An historical control study will also be conducted using data from the Self-Harm Monitoring System for Victoria to examine the impact of the service on rates of self-harm and suicide-related presentations to ED, and compare trends prior to and following commencement of the HOPE aftercare service. In addition, dynamic systems modelling will be used to assess the future scalability of the service.DiscussionFindings from this evaluation will determine the effectiveness, including cost-effectiveness, of the HOPE aftercare service and describe the implementation context. They will inform the future development and sustainability of this and other similar services across Australia and internationally.Trial registrationThis trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 19th December 2023 (Registration number ACTRN12623001332617). We do not foresee any amendments to this protocol however, if any unforeseen modifications are required, they will be submitted to ANZCTR.Trial sponsorOrygen, 35 Poplar Road, Parkville, VIC, 3052, Australia.

OGC SO23 - Audit on Enhanced Recovery After Surgery (ERAS) in Oesophago-gastric Resections for Cancers

Abstract Background Enhanced Recovery After Surgery (ERAS) protocols, have been designed to guide clinicians in managing patients post-operatively, reducing hospital stay, complications and readmissions. Our trust’s ERAS protocol includes guidance on oral intake initiation, drain, catheter and epidural removal, investigation frequency, medications required on discharge and early mobilization. However, implementation of ERAS protocols in complex oncological surgery can be challenging, due to the multiple factors included and increasing complexity. We aimed to assess the compliance of ERAS implementation in a high volume resectional oesophago-gastric unit, and subsequent impact on morbidity. Method A retrospective review of all patients who underwent oesophago-gastric resections during March-April 2024 was performed. Patients were included if they completed an oesophagectomy, or subtotal/total gastrectomy resection for cancer. Electronic records and medical notes were reviewed and compared to all aspects of the trust’s ERAS protocol. The adherence percentage to the protocol was calculated. Results 20 patients underwent surgery. 85% started their oral diet on time per ERAS protocol. Adherence to ERAS was lowest for epidural (52.6%, 95% within 24-hours of target), catheter (55%, 90% within 24-hours of target), apical (55.6%, 100% within 24-hours of target), basal (53.8%, 85.7% within 24-hours of target), and abdominal drain removals (81.8%, 90.9% within 24-hours of target). All patients mobilized within four days post-op, with 65% achieving daily mobilization. VTE prophylaxis was prescribed for all, and discharge medication adherence ranged from 86.7% to 100%. The mean hospital stay was 9 days post-oesophagectomy, with a 3.2% emergency department return rate. Conclusion Implementation of an ERAS protocol is feasible in complex oesophago-gastric cancer surgery. Effective involvement and training of allied health, specialist pain services and the whole surgical team can decrease morbidity and length of stay in oesophagectomy, while avoiding excess emergency department presentations. Ongoing training and feedback of allied health, pain services, and surgical team at all levels is important to ensure adequate compliance.

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.