Emergency Department Screening Research Articles

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments.

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

Implementation Barriers Encountered During a Universal Suicide Screening Program in Pediatric Emergency Departments.

Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs. Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported. Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening. Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

Catching Suicide Before It Harms: Universal Suicide Screening in a Pediatric Emergency Department.

Suicide is the second leading cause of death in people aged 10 to 24 years. We aim to assess the effectiveness of universal suicide screening in a pediatric ED. Since April 7, 2019, all patients 10 years and older who presented to the pediatric ED of our freestanding children's hospital were screened with the validated Columbia Suicide Severity Rating Scale and categorized as mild, moderate, or severe risk for suicide. Screenings from 2019 were reviewed by investigators. All children aged 10 to 18 years who were screened were included. Data collected included demographic information, previous ED visits, past chief complaints), suicidal ideation, suicide attempt, and disposition. A total of 11,469 subjects were screened for suicide risk. Of those screened, 340 were positive on Columbia Suicide Severity Rating Scale, and 5 were excluded for being outside of the age range. Of the remaining 335 subjects who screened positive, 116 (34.5%) of them presented with a primarily medical chief complaint. A total of 120 subjects screened mild risk (35.8%), 46 were moderate (13.7%), and 169 were severe (50.4%). Overall, 141 positive subjects were admitted for mental health concerns. Several patients who screened positive for suicide risk did not present with a mental health concern. Nearly half of screen-positive children who were admitted for mental health concerns had been seen in the ED in the year before their visit. Initiation of universal suicide screening in the pediatric ED identified a significant number of children with unrecognized suicide risk.

Healthcare Team Members’ Views on Social Determinants of Health Screening and Referral Practices in a Pediatric Emergency Department

Healthcare Team Members’ Views on Social Determinants of Health Screening and Referral Practices in a Pediatric Emergency Department

No Patient Left Behind: A Novel Paradigm to Fulfill Hepatitis C Virus Treatment for Rural Patients.

This study evaluates a novel multidisciplinary program providing expanded access to hepatitis C virus (HCV) treatment for rural Appalachian patients in South Carolina. This program identified patients via an opt-out emergency department screening program, and it aimed to achieve HCV cure by using community paramedics (CPs) to link and monitor patients from treatment initiation through 12-week sustained virologic response (SVR). Patients aged ≥18 years who were HCV RNA positive were eligible for enrollment if they failed to appear for a scheduled HCV appointment or reported barriers to accessing office-based treatment. CPs provided home visits (initial and 4, 12, and 24 weeks) using a mobile Wi-Fi hotspot to support telemedicine appointments (compliant with the Health Insurance Portability and Accountability Act) and perform focused physical assessments, venipuncture, and coordinated home delivery of medications. Statistics described participant characteristics, prevalence of SVR, and patient satisfaction results at 12 weeks posttreatment. Thirty-four patients were eligible for SVR laboratory tests by 31 August 2023; the majority were male (61.7%) and White (64.7%) with an average age of 56 years (SD, 11.7). Twenty-eight (82.4%) completed treatment and achieved 12-week SVR. Six (17.6%) were lost to follow-up. Two-thirds strongly agreed that they were satisfied with the overall care that they received, and half strongly agreed that their overall health had improved. This CP-augmented treatment program demonstrated success curing HCV for rural patients who lacked access to office-based treatment. Other health care systems may consider this novel delivery model to treat hard-to-reach individuals who are HCV positive.

Screening for harmful substance use in emergency departments: a systematic review

BackgroundSubstance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use.MethodsWe included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results.ResultsOur search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82–85% and specificities 70–77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies’ risk of bias were mostly high or uncertain.ConclusionsSix screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial

Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Management of suicidal risk in the emergency department: A clinical pathway using the computerized adaptive screen for suicidal youth.

Given the critical need for efficient and tailored suicide screening for youth presenting in the emergency department (ED), this study establishes validated screening score thresholds for the Computerized Adaptive Screen for Suicidal Youth (CASSY) and presents an example of a suicide risk classification pathway. Participants were primarily from the Study One derivation cohort of the Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) enrolled in collaboration with Pediatric Emergency Care Applied Research Networks (PECARN). CASSY scores corresponded to the predicted probabilities of a suicide attempt in the next 3 months and risk thresholds were classified as minimal (<1%), low (1%-5%), moderate (5%-10%), and high (>10%). CASSY scores were compared to risk thresholds derived from clinical consensus and ED complaints and dispositions. CASSY risk thresholds were also examined as predictors of future suicide attempts in the Study Two validation cohort of ED-STARS. A total of 1452 teens were enrolled with a median age of 15.2 years, 59.5% were female, 55.6% were White, 22% were Black, 22.3% were Latinx, and 42.8% received public assistance. The clinical consensus suicide risk groups were strongly associated with the CASSY-predicted risk thresholds. Suicide attempts in the Study Two cohort occurred at a frequency consistent with the CASSY-predicted thresholds. The CASSY can be a valuable tool in providing patient-specific risk probabilities for a suicide attempt at 3 months and tailor the threshold cutoffs based on the availability of local mental health resources. We give an example of a clinical risk pathway, which should include segmentation of the ED population by medical versus psychiatric chief complaint.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4weeks before presentation. Screening should ideally be routine, prompt (<4h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department

There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV. This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening. The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%. An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing. Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients.

Identification of Suicide Risk in a Pediatric Psychiatric Emergency Setting: Comparing the Ask Suicide-Screening Questions and the Kiddie-Computerized Adaptive Test-Suicide Scale

ABSTRACT While the emergency department (ED) is an important setting for identifying youth with psychiatric symptoms and connecting them to services, the demands of the ED make efficient and accurate measurement essential in the implementation of mental health screening. The Kiddie-Computerized Adaptive Test (K-CAT), a new electronically administered measure that offers quick and comprehensive assessment across several mental health domains, may be particularly useful in this setting. Given current recommendations for youth suicide risk screening in EDs, this study compared the K-CAT-Suicide Scale (K-CAT-SS) and the Ask Suicide-screening Questions (ASQ), a widely used measure in EDs, in a sample of participants presenting to a pediatric, psychiatric emergency setting. The measures agreed on the presence of suicide risk in over 85% of cases (κ = 0.59), and the characteristics of youth who screened at risk on both were similar. Cases of disagreement were more often male and more often had educational accommodations. They had lower symptom levels of and were less often diagnosed with internalizing disorders and were less often identified as high risk by ED psychiatrists and psychologists. Examination of item endorsement patterns in cases of disagreement revealed important areas of future study, including the role of caregiver report in suicide risk screening, item comprehension concerns, and the validity of assessing youth with neurodevelopmental disabilities. While additional research would be beneficial into its psychometrics when deployed in real-world settings, the K-CAT-SS should be considered a viable alternative for suicide risk screening in EDs.

Increasing and sustaining blood-borne virus screening in Spain and Portugal throughout the COVID-19 pandemic: a multi-center quality improvement intervention.

Around 57,000 people in Spain and Portugal currently living with HIV or chronic hepatitis C are unaware of their infection. The COVID-19 pandemic severely disrupted screening efforts for these infections. We designed an intervention to increase and sustain opportunistic blood-borne virus (BBV) screening and linkage to care (SLTC) by implementing the TEST model. The Plan Do Study Act (PDSA) method of quality improvement (QI) was implemented in 8 healthcare organizations (HCOs), including four hospitals, two clusters of community health centers, and two community-based organizations (CBOs). Baseline assessment included a review of BBV SLTC practices, testing volume, and results 12 months before the intervention. Changes in BBV testing rates over time were measured before, during, and after the COVID-19 lockdowns in 2020. A mixed ANOVA model was used to analyze the possible effect on testing volumes among HCOs over the three study periods. BBV testing was integrated into normal clinical flow in all HCOs using existing clinical infrastructure and staff. Electronic health record (EHR) systems were modified whenever possible to streamline screening processes, implement systemic institutional policy changes, and promote QI. Two years after the launch of the intervention in screening practices, testing volumes increased by 116%, with formal healthcare settings recording larger increases than CBOs. The start of the COVID-19 lockdowns was accompanied by a global 60% decrease in testing in all HCOs. Screening emergency department patients or using EHR systems to automate screening showed the highest resilience and lowest reduction in testing. HCOs recovered 77% of their testing volume once the lockdowns were lifted, with CBOs making the fullest recovery. Globally, enhanced screening techniques enabled HCOs to diagnose a total of 1,860 individuals over the research period. Implementation of the TEST model enabled HCOs to increase and sustain BBV screening, even during COVID-19 lockdowns. Although improvement in screening was noted in all HCOs, additional work is needed to develop strong patient linkage to care models in challenging times, such as global pandemics.

(O-E1) Food Insecurity and Housing Instability Screening and Follow-up in a Pediatric Emergency Department

(O-E1) Food Insecurity and Housing Instability Screening and Follow-up in a Pediatric Emergency Department

Perspectives on elder mistreatment screening and responding in emergency departments: A qualitative study with survivors.

Elder Mistreatment (EM) occurs in approximately 10% of older adults and is associated with trauma-related outcomes including depression, anxiety, post-traumatic stress disorder, and early mortality. Low screening and older adult self-reporting rates, especially within Emergency Departments represent missed opportunities for identify and mitigate future EM occurrences and consequences. To date, no studies have obtained EM survivors perspectives of EM screening and response practices in emergency departments. Semi-structured interviews with 19 EM survivors with Adult Protective Services validated EM were completed in the older adult's home. The Elder Mistreatment Emergency Department Screening and Response Tool (EM-SART) was used to guide the interview questions. All interviews were recorded, transcribed, and analyzed using qualitative thematic analyses. The participants were mostly female (63%) and white (58%) with an average age of 74years. Physical abuse accounted for 67% of the EM incidents. Three themes emerged indicating the survivor preference for (1) building rapport and approaching the older adult with compassion and care, (2) setting the context before asking the EM questions, and (3) allowing mutuality, collaborative work, and shared decision-making during the response. Older adults are agreeable and willing to self-report and actively engage in the EM screening and response practices in the emergency department if trauma-informed care principles are utilized.

Emergency department contribution to HCV elimination in the Iberian Peninsula

BackgroundUndiagnosed cases of hepatitis C virus (HCV) infection result in significant morbidity and mortality, further transmission, and increased public health costs. Testing in emergency departments (EDs) is an opportunity to expand HCV screening. The goal of this project was to increase the proportion of eligible patients screened for HCV in urban areas.MethodsAn opportunistic automated HCV screening program was implemented in the EDs of 4 public hospitals in Spain and Portugal at different periods between 2018 and 2023. HCV prevalence was prospectively evaluated, and single-step or reflex testing was used for confirmation in the same sample.ResultsMore than 90% of the population eligible for testing were screened in the participating centers. We found HCV antibody seroprevalence rates ranging from 0.6 to 3.9%, with between 19 and 53% of viremic individuals.ConclusionsOpportunistic HCV screening in EDs is feasible, does not disrupt ED activities, is highly effective in increasing diagnosis, and contributes to WHO’s HCV elimination goals.

THE EMED TOOLKIT: COLLABORATION TO IMPROVE ELDER MISTREATMENT SCREENING AND RESPONSE

Abstract The National Collaboratory to Address Elder Mistreatment (The Collaboratory) is a group of elder mistreatment (EM) researchers, clinicians, and advocates who came together with the goal of improving elder mistreatment identification and response in hospital emergency departments (ED). Since its inception in 2017, the Collaboratory has prioritized working in close collaboration with health care and aging services providers as well as older adult survivors to develop, test, and disseminate the Elder Mistreatment Emergency Department Toolkit (EMED Toolkit). The EMED Toolkit is a set of streamlined tools designed to improve EM screening and response in hospital EDs and foster improved collaboration between the hospital and community-based services. The EMED Toolkit is comprised of four core components 1) an online staff survey to assess EM practice and drive system change 2) the evidence-based EM Screening and Response Tool designed to efficiently screen all older adult patients for potential mistreatment, 3) online training modules to educate ED staff on elder mistreatment identification and response, including use of the screening tool, and 4) a Community Connections Roadmap designed to help EDs identify and establish connections with community-based services that can support safe discharge and provide ongoing support to older adults experiencing and at risk for mistreatment. In this presentation we will summarize results from a feasibility study testing EMED Toolkit implementation at five hospitals in the US, describe the Collaboratory’s approach to disseminating the EMED Toolkit more widely through local, regional, and national systems change initiatives, and share lessons learned from our efforts.

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.

Social connectedness and adolescent suicide risk.

Despite evidence of the importance of interpersonal connectedness to our understanding of suicide risk, relatively little research has examined the protective and buffering effects of connectedness among adolescents. The aims of this study were to determine: (a) whether overall connectedness (composite of family, peer, and school) and specific domains of connectedness were related to a lower likelihood of suicide attempts, and (b) whether these factors buffer the prospective risk of suicide attempt for high-risk subgroups (i.e., recent suicidal ideation and/or lifetime history of suicide attempt, peer victimization, or sexual and gender minority status). Participants were 2,897 adolescents (64.7% biological female), ages 12 to 17 (M = 14.6, SD = 1.6), recruited in collaboration with the Pediatric Emergency Care Applied Research Network (PECARN) from 14 emergency departments for the Emergency Department Screen for Teens at Risk for Suicide Study (ED-STARS). Suicide risk and protective factors were assessed at baseline; 3- and 6-month follow-ups were completed (79.5% retention). Multivariable logistic regressions were conducted, adjusting for established suicide risk factors. Higher overall connectedness and, specifically, school connectedness were associated with decreased likelihood of a suicide attempt across 6 months. Overall connectedness and connectedness domains did not function as buffers for future suicide attempts among certain high-risk subgroups. The protective effect of overall connectedness was lower for youth with recent suicidal ideation or a suicide attempt history than for those without this history. Similarly, overall connectedness was protective for youth without peer victimization but not those with this history. Regarding specific domains, family connectedness was protective for youth without recent suicidal ideation or a suicide attempt history and peer connectedness was protective for youth without peer victimization but not youth with these histories. In this large and geographically diverse sample, overall and school connectedness were related prospectively to lower likelihood of suicide attempts, and connectedness was more protective for youth not in certain high-risk subgroups. Results inform preventive efforts aimed at improving youth connectedness and reducing suicide risk.

A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework

BackgroundValidated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021).MethodologyA comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using “Best fit” framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively. FindingsThis is the first known synthesis of qualitative research on HCW’s experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators.Trial registrationPROSPERO: CRD42020188712 05/07/20.

Systematic review of predictors of hospitalisation for non-specific low back pain with or without referred leg pain.

Significant costs and utilisation of healthcare resources are associated with hospitalisations for non-specific low back pain despite clinical guidelines recommending community-based care. The aim of this systematic review was to investigate the predictors of hospitalisation for low back pain. A protocol was registered with PROSPERO international prospective register of systematic reviews (#CRD42021281827) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Database search of Ovid Medline, Emcare, Embase, PsycINFO, Cochrane Library, PEDro and OTSeeker was conducted. Studies were included if they examined a predictor of hospitalisation for non-specific low back pain with or without referred leg pain. Data was extracted and descriptively synthesised. Risk of bias of included studies was assessed using the Critical Appraisal Skills Programme Checklists. There were 23 studies published over 29 articles which identified 52 predictor variables of hospitalisation for low back pain. The risk of hospitalisation was grouped into themes: personal, health and lifestyle, psychology, socioeconomic, occupational, clinical, and health systems and processes. There was moderate level evidence that arrival to an emergency department via ambulance with low back pain, and older age increase the risk of hospitalisations for low back pain. There was low level evidence that high pain intensity, past history of low back pain, opioid use, and occupation type increase the risk of hospitalisation for low back pain. Further research into psychological and social factors is warranted given the paucity of available studies. Hospital avoidance strategies, improved patient screening and resource utilisation in emergency departments are considerations for practice.