Emergency Department Discharge Research Articles

Rural disparities in emergency department utilization for migraine care.

To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences. Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence. This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups. One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001). This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.

Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge

Pediatric readiness is essential for all emergency departments (EDs). Children's experience of care may differ according to operational challenges in children's hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges. To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022. This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children's hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs. Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022. Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours). A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children's hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites. In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.

Descriptive evaluation of patients receiving one-time intravenous vancomycin doses at a large academic medical center emergency department

BackgroundIntravenous (IV) vancomycin is commonly used to treat a variety of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). The practice of administering a single dose of IV vancomycin prior to emergency department (ED) discharge may be clinically ineffective and foster antimicrobial resistance. Furthermore, this practice introduces an unnecessary infection risk along with preventable adverse effects while potentially increasing ED length of stay (LOS). There is a paucity of literature identifying patient characteristics and objective findings in this patient population, which may foster future antimicrobial stewardship initiatives in the ED. MethodsThis was a single-center, retrospective, descriptive analysis of adult patients seen in the ED between January 2020 and January 2023 who received a single dose of IV vancomycin and were subsequently discharged from the ED without hospital admission. Information was collected on patient demographics and select comorbidities, vancomycin indication and dosing, ED LOS, initial vitals and labs, concomitant antibiotics administered, culture results, 30-day return ED visits and admissions, and antibiotics prescribed at ED discharge. ResultsA total of 295 patients met inclusion criteria. A total of 32.1% of patients met SIRS criteria. The most commonly selected order indication for IV vancomycin was “skin and skin structure infection” (41%). A total of 86.1% of patients received concomitant antibiotics in the ED and only 54.6% of patients were prescribed oral antibiotics at ED discharge. A total of 80% of patients had at least one culture obtained during the ED visit. In those who had at least one culture obtained, 78.4% of patients had negative cultures and 4.2% of patients had MRSA positive cultures, with MRSA skin cultures being the most common (3.1%). Return ED visits and admissions within 30 days were not statistically significantly different between patients who did and did not receive oral antibiotics at ED discharge. ConclusionsDespite a lack of clinical efficacy reported in prior literature and the potential risks, administration of a one-time dose of IV vancomycin prior to ED discharge is commonly encountered in clinical practice. There are opportunities for enhanced antimicrobial stewardship related to IV vancomycin use in the ED. Areas of future focus include the utilization of oral antimicrobials when clinically appropriate, particularly for skin and soft tissue infections, and clarification of antibiotic allergies.

Implementation of the European Society of Cardiology 0/3-hour accelerated diagnostic protocol, using high sensitive troponin T: a clinical practice evaluation of safety and effectiveness involving 3003 patients with suspected acute coronary syndrome

BackgroundThere have been relatively few studies detailing the real-world effectiveness and safety of accelerated diagnostic protocols (ADP), using high sensitivity cardiac troponin (hs-cTn).ObjectiveTo analyse the safety and effectiveness of early...

Development of the COMET tool: Caregiver‐reported Outcome Measure for Emergency care Transitions

AbstractBackgroundDespite a recognized need for more robust metrics, caregiver‐reported outcome measures have not been developed for care partners of persons living with cognitive impairment (PLWCI) navigating emergency department (ED)‐to‐community care transitions. Our objective was to develop the Caregiver‐reported Outcome Measure for Emergency care Transitions (COMET) tool through a 5‐phase process.MethodsThe study was conducted in four EDs and included care partners of PLWCI discharged from the ED identified by validated screening tools. In Phase 1, 25 participants completed semi‐structured interviews to identify barriers experienced during ED‐to‐community care transitions. In Phase 2, research team members performed item generation, in which candidate items were developed through findings from Phase 1 qualitative interviews and adaptation of items on existing outcome measures. In Phase 3, we utilized member checking, in which 27 new participants ranked candidate items they felt important for inclusion within the final COMET tool. Phase 4 included 10 cognitive debriefing interviews, in which participants assessed candidate items for comprehensiveness, content validity, and comprehension. In Phase 5, 19 multidisciplinary stakeholders participated in a modified Delphi approach to generate the COMET tool.ResultsPhase 1 identified four major barriers experienced by care partners of PLWCI during ED‐to‐community care transitions: 1) unique care considerations while in the ED setting impact the perceived success of the care transition, 2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, 3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and 4) navigating the health care system after an ED encounter was perceived as difficult by care partners. Phase 2 generated 50 candidate items grouped into 3 domains: discharge process, care transition, and impact on the caregiver. Phase 3 quantitatively identified high‐ and low‐scoring candidate items for inclusion in the final COMET tool. Phase 4 resulted in revisions to the wording of several candidate items. Phase 5 resulted in the 19‐item COMET tool.ConclusionsDevelopment of the COMET tool will provide a means for caregiver‐centric outcome assessment of interventions targeting ED‐to‐community care transitions among PLWCI.

Telemedicine Triage Model for Infusion Center-Based Management of Uncomplicated Acute Sickle Cell Pain Episodes

Introduction: Patients with sickle cell disease (SCD) develop acute episodes of pain for which they seek care in the hospital emergency department (ED). Infusion center (IC)-based care is an effective alternate treatment strategy for management of uncomplicated pain episodes. However, at our center, we could not obtain institutional buy in for dedicated IC resources. Hence, we developed a telemedicine-guided “add on” IC model, embedded within our institution's cancer infusion services. Here, we evaluate the feasibility of our telemedicine-guided IC model and its effectiveness in managing acute pain episodes and impact on SCD patient care. Methods: A multi-disciplinary team consisting of the SCD clinical team including Nurse Case Manager, Advanced Practice Provider (APP), MD and the IC team including IC leadership, IC charge RN, IC scheduler was assembled. An agreement was made between the SCD team and IC leadership that at least one “add on slot” would be made available for an acute SCD pain visit every day. A workflow was created integrating telemedicine for communication with patients and team members alike, and all team members were educated regarding the workflow (Figure 1). IC leadership was re-engaged when changes needed to be made to the workflow to accommodate more IC visits. Visit numbers for IC visits, emergency department (ED) same day discharges and inpatient (IP) hospitalizations were collected from the electronic medical record and compared for pre-IC development (Jan 1, 2017- Dec 31, 2018) and post IC (January 1, 2021 - Dec 31, 2022). Statistical analysis was performed using Graphpad/Prism assuming nonparametric distribution where applicable. Results: We were able to successfully implement our telemedicine-based IC workflow for management of acute SCD pain. Given the rapid increase in IC requests and need for accommodating more than one patient a day, we engaged nursing leadership and re-designed the workflow to identify additional “add on” slots at various IC locations in our health system, added extended hours and weekend capacity. IC visits for uncomplicated pain episodes increased nearly 9 fold, from 132 visits in the pre-IC period to 1151 visits in the post IC period. Seventeen patients used the IC in the pre-telemedicine period and 53 patients used the IC in the post-telemedicine period. The number of ED same day discharges decreased by 35.2%, from 372 visits in pre-IC phase to 241 visits in post IC period. The number of IP hospitalizations went from 281 to 278. ED visits per IC user per year decreased from 10.9 to 2.4 and IP hospitalizations per IC user per year decreased from 8.3 to 2.6. There was a positive correlation between number of IC visits and ED discharges (Spearman r 0.27, p= 0.06) and between number of IC visits and inpatient hospitalizations (Spearman r 0.4, p=0.006), indicating that the patients who were high users of IC based services also had high rates of ED use and hospitalizations. Twenty four patients who used the IC in 2022 did not have same day ED discharges, 15 patients did not have IP stays and 10 patients did not have IP or ED visits in 2022. Among these 10 patients, 8 had their first IC contact under the telemedicine triage IC model (2021-2022). Conclusions: Telemedicine based IC triage can be a successful model for delivery of IC based care for management of acute SCD pain and of great value in settings where dedicated resources are not available. The total number of ED discharges decreased after incorporation of our model, as did both ED discharges and IP hospitalizations per IC user per year. Patients with high numbers of IC visits were also high utilizers of hospital-based services. A cohort of patients were able to use the IC alone for pain management and did not use the ED or get hospitalized.

Delayed Management of Sickle Cell Disease Vaso-Occlusive Episodes and the Impact on Prolonged Hospitalizations at a Single Academic Center

Introduction: Sickle Cell Disease (SCD) affects nearly 100,000 people in the United States (Centers for Disease Control and Prevention, 2023). Vaso-occlusive episode (VOE) is the most common reason for hospitalization in SCD. Many providers are unfamiliar with the pain management timing and dosages required to adequately treat these episodes (Jang et al., J Transl Med 2021). Nationally, areas with comprehensive sickle cell centers have shown decreased hospital utilization, fewer VOEs, and improved quality of life (Oyedeji et al. JAMA 2020). Even in areas without a comprehensive center, implementing individualized pain care plans for SCD has reduced admission rates of high-utilizing patients while not impacting their pain rating scores (Welch-Coltrane et al. Pain Medicine 2021). Our academic hospital, Oregon Health and Science University (OHSU), lacks a comprehensive SCD center and VOE treatment plans are not easily accessible for these patients. We conducted a retrospective analysis on a cohort of patients with SCD to investigate the factors influencing the length of emergency department (ED) and hospital stays for VOE. We aim to identify if implementing individualized pain plans via a standardized template within the electronic health record (EHR) for these patients will decrease hospital admission, length of stay and time to ED discharge. We also aim to integrate individualized pain plans into the EHR that would allow for direct exposure to the care team by creating plans that are easily accessible, reviewed, and routinely utilized for clinical decision-making. Methods: We performed a preliminary retrospective analysis of encounters (n=107) from 2008-2023 at OHSU, where the primary diagnosis was either a VOE or an equivalent diagnosis. Based on data demonstrating earlier maximum opioid doses leading to shortened hospital stays in frequent pain patients, we recorded the timing of the first opioid and morphine milliequivalents per hour in the first 24 hours (Payne et al. Pediatr Blood Cancer 2018). Additionally, we recorded the length of stay, admission rates, time to first IV fluid, and the type of IV fluid used. We performed a linear regression analysis on the collected data with the dependent variable as the length of stay across the independent variables of time to first opioid, time to first intravenous fluid, and morphine milliequivalents per hour during the first 24 hours after presentation. Results: Eighteen patients accounted for the 107 analyzed encounters. Thirteen patients (72%) had Hgb-SS disease, 2 (11%) had Hgb-SC disease, and 3 (17%) had Hgb-S-beta thalassemia. Sixty-two admissions (58%) were ED discharges, and 45 (42%) were ED to hospital admissions. The length of stay and time to the first opioid positively correlated with p=0.005 (Figure 1a). The length of stay and time to first intravenous fluid administration was also positively correlated with p=0.01. The length of stay and morphine milliequivalents per hour in the first 24 hours were negatively correlated with p&amp;lt;0.0001 (Figure 1b). Conclusions: Longer time to administration of opioids and intravenous fluids correlated with a longer length of stay in both the ED and the hospital. Additionally, lower morphine milliequivalents in the first 24 hours of presentation were associated with a prolonged hospital stay at our institution. We hypothesize that these three factors are secondary to delays in care and inappropriate initial treatment of VOE. To address these factors, we aim to implement standardized pain plans in the EHR of our institution. Implementation of individualized pain plans, particularly in the ED, has led to the earlier initiation of opioids (Della-Moretta et al. Ann Emerg Med 2020). We anticipate similar effectiveness for timely and appropriate fluid administration and adequate opioid dosing. We plan to continue retrospective analysis and compare this data to VOE encounters post-implementation. By implementing individualized plans that are integrated within the EHR and efficiently utilized by the care team, we hope to improve VOE management at our institution with decreased length of stay, less ED to hospital admissions, and improved patient satisfaction.

Race and Ethnicity and Emergency Department Discharge Against Medical Advice

Although discharges against medical advice (DAMA) are associated with greater morbidity and mortality, little is known about current racial and ethnic disparities in DAMA from the emergency department (ED) nationally. To characterize current patterns of racial and ethnic disparities in rates of ED DAMA. This cross-sectional study used data from the Nationwide Emergency Department Sample on all hospital ED visits made between January to December 2019 in the US. The main outcome was odds of ED DAMA for Black and Hispanic patients compared with White patients nationally and in analysis adjusted for sociodemographic factors. Secondary analysis examined hospital-level variation in DAMA rates for Black, Hispanic, and White patients. The study sample included 33 147 251 visits to 989 hospitals, representing the estimated 143 million ED visits in 2019. The median age of patients was 40 years (IQR, 22-61 years). Overall, 1.6% of ED visits resulted in DAMA. DAMA rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and White (1.4%) patients, males (1.7%) compared with females (1.5%), those with no insurance (2.8%), those with lower income (<$27 999; 1.9%), and those aged 35 to 49 years (2.2%). DAMA visits were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%). Odds of DAMA were greater for Black patients (odds ratio [OR], 1.45; 95% CI, 1.31-1.57) and Hispanic patients (OR, 1.16; 95% CI, 1.04-1.29) compared with White patients. After adjusting for sociodemographic characteristics (age, sex, income, and insurance status), the adjusted OR (AOR) for DAMA was lower for Black patients compared with the unadjusted OR (AOR, 1.18; 95% CI, 1.09-1.28) and there was no difference in odds for Hispanic patients (AOR, 1.03; 95% CI, 0.92-1.15) compared with White patients. After additional adjustment for hospital random intercepts, DAMA disparities reversed, with Black and Hispanic patients having lower odds of DAMA compared with White patients (Black patients: AOR, 0.94 [95% CI, 0.90-0.98]; Hispanic patients: AOR, 0.68 [95% CI, 0.63-0.72]). The intraclass correlation in this secondary analysis model was 0.118 (95% CI, 0.104-0.133). This national cross-sectional study found that Black and Hispanic patients had greater odds of ED DAMA than White patients in unadjusted analysis. Disparities were reversed after patient-level and hospital-level risk adjustment, and greater between-hospital than within-hospital variation in DAMA was observed, suggesting that Black and Hispanic patients are more likely to receive care in hospitals with higher DAMA rates. Structural racism may contribute to ED DAMA disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups. Monitoring variation in DAMA by race and ethnicity and hospital suggests an opportunity to improve equitable access to health care.

It's Time to Act: Contextualizing the Prevalence of Sexually Transmitted Infections in Adolescents and Young Adults with Sickle Cell Disease

Background: Preventing sexually transmitted infections (STIs) is a key aspect of healthcare for adolescents and young adults (AYAs). Those with sickle cell disease (SCD) may be at particularly high risk given health disparities, knowledge gaps, negative reproductive health outcomes, and barriers to comprehensive sexual and reproductive healthcare for this underserved minority population. While studies show that risky sexual behavior is prevalent in AYAs with SCD (AYAs-SCD), it remains unclear how the prevalence of STIs in AYAs-SCD compares to STI prevalence seen in Black AYAs and AYAs in general. Contextualizing this problem will inform its urgency and potential mitigation strategies. As such, the aims of this study were to examine the prevalence of STIs in AYAs-SCD who were evaluated in the emergency department (ED) and/or admitted for any reason and to compare them to Black and non-Black AYAs in the same setting. Methods: We used the Pediatric Health Information System (PHIS) database, an administrative database of clinical data from &amp;gt;50 children's hospitals in the United States, to query ED and hospital discharges involving patients aged 13 - 25 years between 01/01/2022 - 05/31/2023. We identified patients with SCD (any genotype) using SCD diagnosis codes. Only the first encounter for each patient was used. STIs were identified using diagnosis codes for specific STIs, such as chlamydia trachomatis, neisseria gonorrhea, trichomonas vaginalis, syphilis, human immunodeficiency virus, and herpes simplex virus, as well as codes for non-specified STIs. STI prevalence was defined as the percentage of encounters with any STI diagnosis during the study period. STI prevalence in AYAs-SCD was compared to Black AYAs and non-Black AYAs without SCD controlling for age and sex. Descriptive statistics were used to summarize data. STI prevalence was summarized with 95% confidence intervals and logistic regression models were used to compare between groups. Significance was set at p-values of &amp;lt;0.05. Results: We identified 3,602 AYAs-SCD, 177,783 Black AYAs, and 534,495 non-Black AYAs (Table 1). In general, AYAs-SCD were older at the time of encounter (16.8 ± 2.6 years) compared to Black AYAs (16.0 ± 2.1 years; p &amp;lt; .0001) and non-Black AYAs (16.0 ± 2.1 years; p &amp;lt;.0001). AYAs-SCD had a higher prevalence of any STI diagnosis (17.1%) compared to controls (Black: 10.7%; p &amp;lt;.0001, non-Black: 11.8%; p &amp;lt;.0001) - even when controlling for age and sex (Figure 1). Discussion: Our results suggest that more than one sixth of AYAs with SCD were diagnosed with STIs when seeking acute care for any reason and that they are diagnosed with STIs more frequently than their Black and non-Black counterparts, even when controlling for age and sex. While understanding testing practices is necessary to determine the true prevalence of STIs in AYAs with SCD, these findings indicate a potential disparity in STI risk for AYAs-SCD that is not accounted for by race. We also identified that despite the potential for delayed physical sexual maturation among those with SCD, youth aged 13-15 years with SCD accounted for a substantial proportion of STI diagnoses. This finding, together with the higher prevalence of STIs among those with SCD aged 13-18 years highlights a potential need to increase STI testing in adolescents with SCD. Finally, females with and without SCD made up the majority of individuals diagnosed with STIs in this sample. Although this may be partially due to the increased STI testing frequency in females reported previously, this high STI burden is important to address, especially considering their disease-related risks of other negative reproductive health outcomes from unprotected sex (e.g., pregnancy). This study was limited by its retrospective nature, inability to account for hospital-specific testing practices, focus on hospital-based encounters, and reliance on coding accuracy. Additional work is needed to explore rates of STI testing in AYAs with SCD, STI prevalence in ambulatory settings, the relationship between STI diagnosis and contraception use in AYAs with SCD, and strategies to address STIs in AYAs with SCD such as standardized testing practices for this population.

Do Children Less Than 3 Years with Sickle Cell Disease Need to be Routinely Admitted with Fever?

Background Due to functional asplenia, patients with sickle cell disease (SCD) are at increased risk of serious bacterial infection (SBI) with encapsulated organisms. With the advent of prophylactic penicillin, Haemophilus and Pneumococcal vaccination, this risk has decreased, though recommendations for admission in young children are not standardized and based on institutional practice. Historically, our standard at Benioff Children Hospital Oakland (CHO) has been to admit all children with SCD &amp;lt; 3 years with fever due to these historical concerns. We hypothesized that in a well appearing febrile cohort, the risk of complication would be very low (i.e., &amp;lt;3-5%), allowing liberalization of this stringent recommendation. Methods After IRB approval, we conducted a retrospective review of electronic medical records of children with SCD &amp;lt;3 years of age admitted with fever (i.e., ≥38.3ºC) from October 1 st, 2013 to May 30 th 2022 at CHO. We excluded patients who presented with fever and other complications in the emergency department (ED) that would have otherwise required admission including: 1) splenic sequestration; 2) acute chest syndrome (ACS); 3) hypoxia and/or respiratory distress; 4) vaso-occlusive crisis (VOC); 5) hemoglobin (Hb) drop ≥2 g/dL from baseline; 6) severe dehydration; 7) seizures or other neurological concerns; 8) complicated/complex medical history; 9) SARS-CoV-2 infection; 10) age &amp;lt;2 months; 11) soft tissue infection; and 12) UA concerning for infection. Results Sixty-four unique patients with 127 encounters were included with baseline features outlined in Table 1. Ninety-seven encounters were excluded due to presenting signs/symptoms. Rate of bacteremia was 1.6% (2 of 127). Twenty-six of the 127 encounters (20%, 21 unique patients) were deemed complicated, due to: 1) bacteremia (n=2); 2) splenic sequestration (n=6); 3) acute chest syndrome (n=1); 4) worsening anemia requiring transfusion (n=11); 5) pain crisis (n=1); 6) persistent fever (n=4) and 7) norovirus gastroenteritis (n=1). Eighty-five percent were in children 2 years or less. Complicated admissions were statistically longer and had lower hemoglobin and platelets at presentation than uncomplicated admissions (Table 2). There was no difference in age, white blood cell count (WBC) and maximum fever during presentation in the ED (Table 2). Fourteen of 26 complications (54%) occurred in the first two days of admission and the rest thereafter. Conclusions Although the rate of bacteremia was low as expected in children with SCD &amp;lt;3 years of age presenting to the ED with fever and without concerning presenting features, the overall rate of complications during admission for those encounters was much higher than our acceptable a priori threshold. Retrospectively, there were no easily discernible presenting features in this otherwise well-appearing cohort to determine need for admission. Complications often occurred beyond day 2 of admission. The majority of complications occurred in children ≤2 years of age; we therefore will continue to admit all children with SCD and fever ≤ 2 years of age with a low threshold for ongoing admission beyond the 48 hour rule out. Institutional standards must closely monitor for increased adverse events if utilizing more lenient ED discharge criteria in this population.

2949. Emergency Department (ED) Discharge Antibiotic Prescription Review by Hospital Pharmacists at a Large Academic Medical Center

Abstract Background Direct patient discharge from the Emergency Department (ED) presents an ideal time to promote antimicrobial stewardship (AS). On March 1, 2021 we initiated a pilot program where ED pharmacists conduct a review of discharge antibiotic prescriptions (abx Rxs). The aim of this program is to ensure appropriate discharge abxs. Willow Pharmacy Epic Analysts, ED and AS pharmacists collaborated on this program which included Epic integration of Rx Discharge Track Board, ED Discharge InBasket, ED Discharge Rx iVent and AS-led education sessions. Methods Data for 2022 ED patients with discharge abx Rxs and iVents were extracted via Epic Reports. The first encounter per patient was included. We compared discharge abx Rxs and patient outcome data in Pharmacy vs No Pharmacy Review Groups (PRG, NPRG). Pharmacy iVents were used as a process measure. Results Among 5747 ED adult patients with discharge abx Rxs, 2638 (46%) were reviewed by pharmacy (PRG). PRG and NPRG had similar prevalence of chronic pulmonary disease (12% vs. 13%), diabetes mellitus (9% vs. 10%), malignancy (8% vs. 9%), peripheral vascular disease (6% vs. 8%), renal disease (4% vs. 5%), and HIV (1% vs. 2%) despite a difference in mean Charlson Comorbidity Index (0.64 vs 0.75, p&amp;lt; 0.01). The primary ED diagnosis was skin and soft tissue, urinary, intra-abdominal infections and pneumonia (25 vs 23%, 18 vs 17%, 8 vs 9%, 5 vs 6%, respectively all p=NS). In PRG, discharge abxs demonstrated an increase use of penicillin (26 vs 24%, p=0.017) and 2nd generation cephalosporin (17 vs 14%, p&amp;lt; 0.001). The PRG also decreased use of 3rd generation cephalosporin (11 vs 12%, p=NS), quinolones (6 vs 7%, p=NS) and clindamycin (1.7 vs 2.4%, p=NS). There was no difference in ED length of stay (LOS 4.8h in each group), C. difficile infection (CDI) within 8 weeks (0.1 vs 0.2%, p=NS), and 30 days repeat ED visit or inpatient admission with the same diagnosis as index ED encounter (2.8 vs 2.6%, p=NS). Pharmacists intervened in 10% (272/2638) of ED abx Rxs with 92% (249/272) acceptance rate. The top 3 pharmacy interventions were recommending alternative abx (42%), dose optimization (31%) and abx duration (6%). Conclusion Engaging pharmacists in ED discharge Rxs review resulted in use of narrower spectrum abx with lower CDI risk without any negative impact on ED LOS and clinical outcomes. Disclosures All Authors: No reported disclosures

169. Positive blood culture after emergency department discharge of patients from a cancer center. Epidemiology, clinical features, and outcome

Abstract Background Cancer patients frequently go to the emergency room (ER) because of fever. Within the approach, blood cultures are taken, and they are often discharged if their clinical condition is stable. The objective of the study is to know the epidemiology, clinical characteristics, and outcome of patients with positive blood cultures after discharge from the emergency department. Methods Between 2021 and 2022, 178 blood cultures taken in the ER were positive for infection. Of these, 93 cases (38%) corresponded to outpatients who were included. Demographic, clinical, and microbiological data were collected. A bivariate analysis comparing the cohort vs. patients that were admitted (controls) from the ER in the same period was done. Results Most frequent oncological diagnosis was breast cancer (21.5%), lymphoma (18.3%), and cervical cancer (11.8%). Forty-nine (53%) had recently been diagnosed with cancer, 52 (55.9%) had received chemotherapy, and 15 (16.1%) had received antibiotics within the previous month. The most frequent reasons for consultation were febrile syndrome (28%), fever after CVC manipulation (20.4%), and fever with urinary symptoms (12%). Antibiotics were prescribed on discharge from the emergency department in 57 patients (61.3%), being adequate in 36.9% of the cases. The isolate was considered to be pathogenic in 84 cases, mainly due to Gram-negative bacilli (n=58, 69%). 72 (77.4%) attended reassessment (due to telephone contact or persistence of symptoms), and 56 (60.2%) were hospitalized. The most frequent bloodstream infections were secondary (n=45, 48.4%) and catheter-related (n=33, 35.5%). Three patients died, and only in one case was it secondary to an infection, compared to 23.5% in the admitted group. The bivariate analysis is reported in Table 1. Conclusion Mortality in discharged patients was low (3%); Close monitoring of positive blood cultures, patient follow-up, and identification of risk factors for adverse outcomes, such as neutropenia, inflammatory response syndrome with high C-reactive protein or Procalcitonin, uncontrolled foci of infection, recent hospitalization, or antibiotic treatment should be considered for admission in this high risk population. Disclosures All Authors: No reported disclosures

Analysis of Patient Adherence to Filling Emergency Department Discharge Prescriptions for Empiric Treatment of Chlamydia

PurposeSexually transmitted infections (STIs) represent an enormous public health burden in the United States. Emergency departments (EDs) are a significant source of medical care, particularly for vulnerable patient populations. Guidelines for the treatment of Chlamydia trachomatis have evolved and now recommend doxycycline 100 mg orally twice daily for 7 days as the primary regimen for adults. However, the single-dose azithromycin regimen can be given during the ED visit, while the new regimen has nonadherence hurdles. The purpose of this study will be determining the rate of ED discharge prescription pick ups of doxycycline for Chlamydia trachomatis infection at two discharge pharmacies. MethodsThis is a retrospective chart review of information contained in the electronic medical record (EMR) from August 1st, 2021 – July 31st, 2022. Adult patients who present to the two EDs in the healthcare system and those who received empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge will be included. Patients who are pregnant, less than 18 years old, those without a Chlamydia trachomatis nucleic acid amplification test during their ED visit, or patients whose antibiotic treatment prescription was sent to a pharmacy other than the two primary discharge pharmacies at the respective medical centers will be excluded. The primary outcome of this study will be determining the rate of emergency department (ED) discharge prescription pick ups of doxycycline for empiric treatment of Chlamydia trachomatis infection at two discharge pharmacies. The secondary outcomes will include the incidence of repeat positive tests between four weeks and 90 days, risk of repeat positive tests in those who do not fill doxycycline, number of positive and negative test results, rate of prescribing adherence to 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines regimens for empiric treatment, and insurance status at the time of discharge fill. ResultsSeven hundred and thirty patients were pulled from the EMR. One hundred of the patients were excluded from the study as they did not receive empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge leaving 630 participants. Among this group, 369 patients were excluded as their discharge prescription was not sent to the discharge pharmacies within the medical system, leaving 261 individuals in the study. Per chart review, 215 of the patients picked up their doxycycline prescription (82.4%) and 46 (17.6%) patients failed to pick up their prescription. Additionally, 43 (16.5) of the patients who were prescribed empiric therapy had a positive chlamydia trachomatis test, while 209 (83.5%) of those had a negative test. This study also showed 188 (72%) patients received treatment according to the current CDC recommendations. ConclusionMajority of patients who received prescriptions from the in-hospital discharge pharmacy picked up their prescriptions.

Reasons for emergency department visits of patients with opioid use disorder at an urban safety-net hospital: A retrospective records review

Objectives: The purpose of this study was to describe the emergency department (ED) visit chief complaints and discharge diagnoses of patients with an opioid use disorder (OUD) empaneled to a primary care clinic.&#x0D; Design: ED visits were retrospectively reviewed through electronic health records. Patients with a history of using multiple substances and medical or psychiatric conditions were compared to those without these conditions.&#x0D; Setting: This study was conducted at Harbor-UCLA ED, a safety-net level one trauma center.&#x0D; Patients and participants: Eligible participants were empaneled to the Harbor-UCLA Family Health Center with a diagnosis of OUD between January 1, 2018, and December 31, 2020.&#x0D; Main outcome measures: The primary outcome measures included number of ED visits, hospital admissions, chief complaints, and discharge diagnoses.&#x0D; Results: The total number of patients was 59. The most common chief complaints were musculoskeletal (34 percent), gastrointestinal (18 percent), general (13 percent), and skin (8.6 percent). The most common discharge diagnoses were musculoskeletal (27 percent), gastrointestinal (20 percent), infectious (11 percent), substance use disorder related (11 percent), psychiatric (7 percent), and cardiovascular (7 percent). Co-occurring alcohol use was associated with a higher number of visits, 3.18 versus 1.15 (p = 0.021), and a higher percentage of patients with frequent visits, 46 percent versus 8 percent (p = 0.008). Patients with diabetes had more frequent visits, 40 percent versus 10 percent (p = 0.036), and were more likely to be admitted, 43 percent versus 15 percent (p = 0.010).&#x0D; Conclusions: This study highlights the importance of screening and the management of alcohol use and diabetes among patients with OUD.

Bridging the gap: a qualitative study of providers' perceptions of a partnered crisis follow-up program for suicidal patients post-emergency department discharge

BackgroundEffective interventions are needed to address suicide risk following discharge from the hospital emergency department or inpatient setting. Studies that examine follow-up contact methods show promise, but little is known about how follow-up programs are implemented in the real world and who is benefitting. The purpose of this formative evaluation and analysis was to gain insight about the usefulness and value of a partnered suicide prevention follow-up program (academic medical center emergency department partnered with a regional suicide prevention center) from the standpoint of psychiatry resident physicians providing direct care and suicide prevention center crisis counselors making follow-up outreach telephone calls to patients.MethodsA qualitative thematic analysis was conducted with focus group data from a convenience sample of psychiatry residents who performed consultations in the emergency department setting and counselors at the suicide prevention center crisis follow-up program. Focus group sessions, using semi-structured question guides, were completed at each participant group’s workplace. Grounded theory techniques were used to guide coding and analytic theme development.ResultsAnalyses resulted in four overarching themes: valuing the program’s utility and benefit to patients, desiring to understand what happens from emergency department discharge to program follow-up, having uncertainty about which patients would benefit from the program, and brainstorming to improve the referral process. Psychiatry residents appreciated the option of an “active” referral service (one that attempts to actively engage a patient after discharge through outreach), while suicide prevention crisis counselors valued their ability to offer a free and immediate service that had potential for fostering meaningful relationships. Both participant groups desired a better understanding of their partner’s program operations, a uniform and smooth referral process, and awareness of who may or may not benefit from program services.ConclusionResults revealed the need for improved communication and implementation, such as expanded inter-agency contacts, consistent provider training, more documentation of the requirements and rules, a consistent message about program logistics for patients, and coordination between the program elements.

Inappropriate requests for cranial CT scans in emergency departments increase overuse and reduce test performance.

The number of non-traumatic urgent cranial computed tomography (NT-UCCT) is exponentially increasing but limited research has been conducted on the quality of clinical justification. Accordingly, we aimed (1) to assess how clinical information in the electronic NT-UCCT request agreed with that provided in the patient's emergency department discharge summary and (2) to analyze the potential effect of those discrepancies on the NT-UCCT overload. Patients undergoing NT-UCCT in 2017-2021 were randomly selected for this retrospective research-board-approved study. Signs and symptoms (S/S) in electronic request and emergency department discharge summary, acute and relevant computed tomography (CT) findings (acute ischemia or hemorrhage, masses, brain edema, or previously undetected hydrocephalus), and final diagnosis at emergency department discharge summary were collected. Concordance between digital request and emergency department discharge summary and their association with both acute and relevant CT findings and final diagnosis were analyzed. We recruited 156 patients: 80 men; mean age, 55. Acute, relevant CT findings were detected in 28 cases (17.9%). The final diagnosis was neurological disease, non-neurological disease, and no definitive diagnosis in 46 (29.5%), 58 (37.2%), and 51 (32.7%) cases, respectively. Full agreement between the electronic request and emergency department discharge summary occurred in only 36 patients (23.1%). Motor deficit was the most frequent false positive electronic request S/S (18; 11.54%), having low positive predictive value (30.30%; 95%CI 15.59-48.71%) andworst association with acute relevant CT findings than when true positive (OR 2.54; 95%CI 0.04-6.21 vs. OR 6.26, 95%CI 2.21-17.78). Nausea/vomiting was the third most common false negative electronic request S/S (13; 10.26%) and reduced the likelihood of acute and relevant CT findings (OR 0.126; 95%CI 0.016-0.971; p = 0.020). False S/S in electronic request predominated in non-neurological diseases (50-60.2% vs. 33-39.8%; p = 0.068). Discrepancies between electronic request and emergency department discharge summary were observed in >75% of patients, leading to unnecessary NT-UCCT tests.

Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response

Objective To compare outcomes of patients presenting to emergency medical services (EMS) with atrial fibrillation with rapid ventricular response (AF-RVR) who did and did not receive prehospital advanced life support (ALS) rate or rhythm control intervention(s). Methods This retrospective cohort study used the 2021 ESO Data Collaborative (Austin, TX) dataset. We identified 9-1-1 scene responses for patients aged 16 to 100 years old presenting with AF and an initial heart rate ≥ 110 beats per minute (bpm). Prehospital ALS interventions for AF-RVR included medications (e.g., calcium channel blockers, beta blockers, etc.) or electrical cardioversion. Outcome measures included prehospital rate control (i.e., final prehospital heart rate < 110 bpm), emergency department (ED) discharge to home, ED and hospital length of stay, and mortality. We also evaluated prehospital adverse events—specifically bradycardia, hypotension, and cardiac arrest. We used propensity score matching to compare outcomes among treated and untreated patients with similar demographic and clinical characteristics. We determined the average treatment effect on the treated (ATET) with 95% confidence intervals (CI) and the number needed to treat (NNT). Results After propensity score matching, prehospital outcomes were available for 4,859 treated patients matched with 4,859 similar untreated patients. Prehospital rate control was more frequent for treated than for untreated patients (41.0% vs. 18.2%, ATET +22.8%, CI: +21.1%; +24.6%, NNT = 5). Hospital outcomes were available for 1,347 treated patients matched with 1,347 similar untreated patients. Treated patients were more likely to be discharged from the ED (37.9% vs. 34.0%, ATET +3.9%, CI: +0.2%; +7.5%, NNT = 26) and less likely to die (4.3% vs. 6.7%, ATET −2.5%, CI: −4.2%; −0.8%, NNT = 40) compared to untreated patients. Hypotension occurred more often in treated patients (ATET +2.6%, CI: +1.5%; +3.7%), but resolved before ED arrival in 73% of affected patients. Otherwise, adverse event rates did not significantly differ for the two groups. Conclusions In this propensity score matched study of patients presenting to EMS with AF-RVR, prehospital ALS interventions were associated with more frequent prehospital rate control, more frequent discharge to home from the ED, and lower mortality.

Assessment of inter-rater reliability of screening tools to identify patients at risk of medication-related problems across the emergency department continuum of care

BackgroundFollowing a national multicentre study, two emergency department (ED) screening tools were developed to determine risk of medication-related problems; one for use at ED presentation and another at ED discharge to the community. This study aimed to determine the inter-rater reliability amongst ED health professionals when applying these screening tools to a series of case scenarios. MethodsA prospective, cross-sectional study was undertaken in the ED of a major metropolitan hospital. Twelve case scenarios were developed following ED observation of a range of patients, which were incorporated into a questionnaire and distributed to 50 health professionals. Inter-rater reliabilities of each explanatory variable of the screening tools and overall assessment were calculated using Fleiss’ multi-rater kappa. ResultsThe questionnaire was completed by 15 doctors, 19 nurses and 16 pharmacists. Fleiss’ kappa showed an overall inter-rater reliability for the ED presentation tool of 0.83 (95% CI 0.83–0.84), indicating near perfect agreement. Fleiss’ kappa for the ED discharge tool was 0.83 (95% CI 0.83–0.85), which also showed near perfect agreement. ConclusionsThe screening tools produced favourable inter-rater reliability amongst ED health professionals. These results have important implications for ensuring consistency of ED decision-making in screening patients at risk of developing medication-related problems.

A Pilot Trial of Continuous Glucose Monitoring Upon Emergency Department Discharge Among People With Diabetes Mellitus

ObjectivePeople with diabetes mellitus, particularly those with limited access to longitudinal care, frequently present to the emergency department (ED). Continuous glucose monitoring (CGM) has been shown to improve outcomes in ambulatory settings, so we hypothesized that it would be beneficial if initiated upon ED discharge. MethodsWe randomized adults with diabetes who were seen in the ED for hypo- or hyperglycemia to either 14 days of flash CGM or care coordination alone. All participants were scheduled to follow up in our diabetes specialty clinic. Outcomes included clinic attendance, the 3-month change in hemoglobin A1c, and repeat ED utilization. ResultsWe recruited 30 participants, including 13 with newly diagnosed diabetes. All but one (97%) had type 2 diabetes. We found no significant difference between the CGM (n = 16) and control (n = 14) groups in terms of clinic attendance (75 vs 64%, P = .61) or repeat ED utilization (31 vs 50%, P = .35), although our power was low. The absolute reduction in A1c was greater in the CGM group (5.2 vs 2.4%, P = .08). Among newly diagnosed participants for whom we had data, 7 out of 7 in the CGM group had a follow-up A1c under 7% compared to 1 out of 3 in the control group (P = .03). Over 90% of patients and providers found the CGM useful. ConclusionsOur data demonstrate the feasibility of starting CGM in the ED, a valuable setting for engaging difficult-to-reach patients. Our pilot study was limited by its small sample size, however, as recruitment in the ED can be challenging.

Abstract 12695: An Atrial Fibrillation Treatment Pathway in the Emergency Department Reduces 30-day Cost of Care

Introduction: The annual cost of care for Atrial Fibrillation (AF) is estimated at $6.65 billion, with nearly 75% attributed to costs of hospitalizations. An AF treatment pathway with expedited follow-up to an AF-specialized clinic has been shown to reduce unnecessary admissions for AF and improve AF quality of care metrics. Goal: Evaluate differences in 30-day cost of care and discharge rate for adults presenting with AF to the emergency department (ED) before and after implementation of an AF treatment pathway. Methods: An AF treatment pathway with expedited follow-up to AF-specialized clinic was implemented at seven hospitals in North Carolina between 2017 to 2020. 30-day cost of care was calculated for patients presenting to ED with primary or secondary diagnosis of AF from 2016 to 2020 (N=12,543) by summing inflation-adjusted charges for initial hospital encounter, outpatient follow-up visits, and repeat hospital encounters for AF within 30 days. An adjusted quintile regression analysis and poisson regression, both with covariables of age, sex, race, CHA2DS2-VASc score and hospital site, were used to compare median 30 day cost of care and rates of ED discharge respectively. Results: Following implementation of the AF treatment pathway, the unadjusted median 30-day cost of care (Pre: $11,351, Post: $8,206), median initial hospital charge (Pre: $10,825, Post: $7,760), median repeat hospital encounter charge for those with repeat presentations within 30 days (Pre: $12,532, Post: $9,470) were all significantly lower (p&lt;0.001). The adjusted median 30-day cost of care was lower (-$1532; 95% CI: $ -2001, $ -1064) and the predicted probability of discharge was greater (Pre: 61.7%, 95% CI: 60.2%, 63,2%; Post: 71.6%, 95% CI: 70.7%, 72.6%) following implementation of AF treatment pathway. Conclusions: Implementation of an AF treatment pathway in the ED is associated with an increase in ED discharge rate and decrease in 30 day costs of care.