Emergency Department Sites Research Articles

388. Co-Testing: Increasing HIV Testing in Patients Undergoing Sexually Transmitted Infection Evaluation in a Large Integrated Healthcare Network

Abstract Background Utah ranks last among states in the percentage (26.5%) of adults ever tested for Human Immunodeficiency Virus (HIV). We hypothesized that linking “co-testing” for HIV to evaluations for sexually transmitted infections (STIs) in Urgent Care (UC) and Emergency Departments (ED) would increase HIV screening. We implemented a multifaceted intervention in the UCs and EDs of our integrated health system and evaluated its impact on HIV co-testing. Methods The initiative included education and HIV test follow-up support along with an electronic medical record-embedded alert (Figure 1). The alert surfaced if gonorrhea (GC), chlamydia (CT), or other STI testing was ordered for patients ≥ 18 years with unknown HIV status and encouraged HIV testing if not already ordered. We sequentially implemented the initiative in 26 UC and 22 ED sites from April 2023 – December 2023. We used interrupted time series analysis to evaluate HIV co-testing rates among eligible GC/CT testing encounters in pre-implementation (April 1st, 2022 – March 31st, 2023) and post-implementation (April 1st, 2023 – March 31st, 2024) UC and ED cohorts. We compared the observed rate to the predicted counterfactual (had no intervention taken place). We also assessed co-testing by social determinants of health (SDOH) categories, alert volume, and system impact on HIV testing and diagnoses. Results During the 24-month study, there were 19,232 GC/CT test encounters: 5,730 UC/2,524 ED pre-implementation and 7,696 UC/3,282 ED post-implementation. In UC, the increase in the observed HIV GC/CT co-test rate vs the predicted was 14.5 percentage points (95% CI 9.08-20.06, p< 0.001) (Figure 2). In the ED, the increase in the observed HIV GC/CT co-test rate vs the predicted was 13.7 percentage points (95% CI 5.75-21.71, p< 0.001). HIV GC/CT co-testing varied by SDOH (Table 1). 4,704 alerts fired (54% UC/46% ED) and resulted in 730 HIV co-tests (225 UC/505 ED), representing a 15.5% engagement rate. Of these 730 alert-initiated HIV co-tests, 5 (0.7%) revealed new HIV diagnoses, representing 29% of all HIV diagnoses in UC and ED during the post-implementation period (Figure 3). Conclusion HIV co-testing in our UC and ED sites increased during a multifaceted initiative. New HIV diagnoses occurred in UC and ED as a result of HIV testing ordered via our alert. Disclosures Bert K. Lopansri, MD, D(ABMM), FIDSA, Cepheid: Grant/Research Support|Seegene: Advisor/Consultant

Disparities in pain management among transgender patients presenting to the emergency department for abdominal pain.

Transgender and gender-diverse (TGD) individuals have a gender identity or expression that differs from the sex assigned to them at birth. They are an underserved population who experience health care inequities. Our primary objective was to identify if there are treatment differences between TGD and cisgender lesbian/gay/bisexual/queer (LGBQ) or heterosexual individuals presenting with abdominal pain to the emergency department (ED). Retrospective observational cohort study of patients ≥12 years of age presenting to 21 EDs within a health care system with a chief complaint of abdominal pain between 2018 and 2022. TGD patients were matched 1:1:1:1 to cisgender LGBQ women and men and cisgender heterosexual women and men, respectively. Propensity score matching covariates included age, ED site, mental health history, and gastrointestinal history. The primary outcome was pain assessment within 60 min of arrival. The secondary outcome was analgesics administered in the ED. We identified 300 TGD patients, of whom 300 TGD patients were successfully matched for a total cohort of 1300 patients. The median (IQR) age was 25 (20-32) years and most patients were treated in a community ED (58.2%). There was no difference between groups in pain assessment within 60 min of arrival (59.0% TGD vs. 63.2% non TGD, p = 0.19). There were no differences in the number of times pain was assessed (median [IQR] 2 [1-3] vs. 2 [1-4], p = 0.31) or the severity of pain between groups (5.5 [4-7] vs. 6 [4-7], p = 0.11). TGD patients were more likely to receive nonsteroidal anti-inflammatory drugs (32.0% vs. 24.9%, p = 0.015) and less likely to receive opioids than non-TGD patients (24.7% vs. 36.9%, p = <0.001). TGD and nonbinary patients, along with LGBQ cisgender women (24.7%) and heterosexual cisgender women (34%), were less likely to receive opioids than LGBQ cisgender men (54%) and heterosexual cisgender men (42.3%, p < 0.01). There was no difference in frequency of pain assessment, regardless of gender identity or sexual orientation. More cisgender men, compared to TGD and cisgender women, received opioids for their pain.

Reasons Explaining High Emergency Department Use in Patients With Mental Illnesses: Different Staff Perspectives.

For patients with mental illnesses (MIs), emergency departments (EDs) are often the entry point into the healthcare system, or their only resort for quickly accessing mental health treatment. A better understanding of the various barriers justifying high ED use among patients with MIs may help recommend targeted interventions that better meet their needs. This explorative qualitative study aimed to identify such barriers and the solutions brought forth to reduce ED use based on the perspectives of clinicians and managers working in EDs, other hospital departments or the community sector. Interviews were conducted between April 2021 and February 2022; 86 mental health professionals (22% were nurses) from four large urban ED sites in Quebec (Canada) were interviewed. Barriers were identified in relation to patient profiles, healthcare system and organisational features and professional characteristics. The key barriers that were found to explain high ED use were patients having serious MIs (e.g., psychotic disorders) or social issues (e.g., poverty), lack of coordination and patient referrals between EDs and other health services, insufficient access to mental health and addiction services and inadequacy of care. Very few solutions were implemented to improve care for high ED users. Better deployment of ED interventions in collaboration with outpatient care may be prioritised to reduce high ED use for patients with MIs. Improvements to the referral and transfer processes to outpatient care, particularly through care plans and case management programs, may be implemented to reduce high ED use and improve outpatient care among patients with multiple health and social needs.

Addressing diagnostic uncertainty and excellence in emergency care—from multicountry policy analysis to communication practice in Australian emergency departments: a multimethod study protocol

IntroductionCommunication failings may compromise the diagnostic process and pose a risk to quality of care and patient safety. With a focus on emergency care settings, this project aims to examine...

Patient Comments and Patient Experience Ratings Are Strongly Correlated With Emergency Department Wait Times.

Hospitals and clinicians increasingly are reimbursed based on quality of care through financial incentives tied to value-based purchasing. Patient-centered care, measured through patient experience surveys, is a key component of many quality incentive programs. We hypothesize that operational aspects such as wait times are an important element of emergency department (ED) patient experience. The objectives of this paper are to determine (1) the association between ED wait times and patient experience and (2) whether patient comments show awareness of wait times. This is a cross-sectional observational study from January 1, 2019, to December 31, 2020, across 16 EDs within a regional health care system. Patient and operations data were obtained as secondary data through internal sources and merged with primary patient experience data from our data analytics team. Dependent variables are (1) the association between ED wait times in minutes and patient experience ratings and (2) the association between wait times in minutes and patient comments including the term wait (yes/no). Patients rated their "likelihood to recommend (LTR) an ED" on a 0 to 10 scale (categories: "Promoter"=9-10, "Neutral"=7-8, or "Detractor"=0-6). Our aggregate experience rating, or Net Promoter Score (NPS), is calculated by the following formula for each distinct wait time (rounded to the nearest minute): NPS=100* (# promoters - # detractors)/(# promoters+ # neutrals+ # detractors). Independent variables for patient age and gender and triage acuity, were included as potential confounders. We performed a mixed-effect multivariate ordinal logistic regression for the rating category as a function of 30minutes waited. We also performed a logistic regression for the percentage of patients commenting on the wait as a function of 30minutes waited. Standard errors are adjusted for clustering between the 16 ED sites. A total of 50 833 unique participants completed an experience survey, representing a response rate of 8.1%. Of these respondents, 28.1% included comments, with 10.9% using the term "wait." The odds ratio for association of a 30-minute wait with LTR category is 0.83 [0.81, 0.84]. As wait times increase, the odds of commenting on the wait increase by 1.49 [1.46, 1.53]. We show policy-relevant bubble plot visualizations of these two relationships. Patients were less likely to give a positive patient experience rating as wait times increased, and this was reflected in their comments. Improving on the factors contributing to ED wait times is essential to meeting health care systems' quality initiatives.

Extremes of Emergency Department Boarding are Associated With Poorer Financial Performance Among Hospitals.

Boarding emergency department (ED) patients is associated with reductions in quality of care, patient safety and experience, and ED operational efficiency. However, ED boarding is ultimately reflective of inefficiencies in hospital capacity management. The ability of a hospital to accommodate variability in patient flow presumably affects its financial performance, but this relationship is not well studied. We investigated the relationship between ED boarding and hospital financial performance measures. Our objective was to see if there was an association between key financial measures of business performance and limitations in patient progression efficiency, as evidenced by ED boarding. Cross-sectional ED operational data were collected from the Emergency Department Benchmarking Alliance, a voluntarily self-reporting operational database that includes 54% of EDs in the United States. Freestanding EDs, pediatric EDs and EDs with missing boarding data were excluded. The key operational outcome variable was boarding time. We reviewed the financial information of these nonprofit institutions by accessing their Internal Revenue Service Form 990. We examined standard measures of financial performance, including return on equity, total margin, total asset turnover, and equity multiplier (EM). We studied these associations using quantile regressions of added ED volume, ED admission percentage, urban versus nonurban ED site location, trauma status, and percentage of the population receiving Medicare and Medicaid as covariates in the regression models. Operational data were available for 892 EDs from 31 states. Of those, 127 reported a Form 990 in the year corresponding to the ED boarding measures. Median boarding time across EDs was 148min (interquartile range [IQR]: 100-216). A significant relationship exists between boarding and the EM, along with a negative association with the hospital's total profit margin in the highest-performing hospitals (by profit margin percentage). After adjusting for the covariates in the regression model, we found that for every 10min above 90min of boarding, the mean EM for the top quartile increased from 245.8% to 249.5% (p <.001). In hospitals in the top 90th percentile of total margin, every 10min beyond the median ED boarding interval led to a decrease in total margin of 0.24%. Using the largest available national registry of ED operational data and concordant nonprofit financial reports, higher boarding among the highest-profitability hospitals (i.e., top 10%) is associated with a drag on profit margin, while hospitals with the highest boarding are associated with the highest leverage (i.e., indicated by the EM). These relationships suggest an association between a key ED indicator of hospital capacity management and overall institutional financial performance.

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition.

The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition. This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay. A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients. Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

IntroductionOpioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and...

Patient Portal Enrollment for Discharged Pediatric Emergency Department Patients: A Multidisciplinary Quality Improvement Project.

Patient portal enrollment following pediatric emergency department (ED) visits allows access to critical results, physician documentation, and telehealth follow-up options. Despite these advantages, there are many challenges to portal invitation and enrollment. Our primary objective was to improve patient portal enrollment rates for discharged pediatric ED patients. A multidisciplinary team of staff from two ED sites developed successful portal enrollment interventions through sequential Plan-Do-Study-Act cycles from October 2020 to October 2021. Interventions included a new invitation process, changes to patient paperwork on ED arrival, staff portal education, and changes to discharge paperwork and the portal website. The team utilized statistical process control charts to track the percentage of eligible discharged patients who received a portal invitation (process measure) and enrolled in the patient portal. Before the study's initiation, less than 1% of eligible patients received patient portal invites or enrolled in the patient portal. Statistical process control charts revealed significant changes in enrollment and baseline shift at both a large academic ED campus and a satellite ED site by May 2021. Improvements in invitation rates were also observed at both campuses. Changes were sustained for over 6 months at both locations. High-reliability interventions and a multidisciplinary approach allowed for significant and sustained improvement in patient portal invitation and enrollment rates in eligible pediatric ED patients. Future study will examine enrollment patterns across patient demographics and further high-reliability interventions.

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol

IntroductionThe burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk...

Comparison of two testing strategies for Mycoplasma genitalium in emergency department patients across a statewide health system

PurposeMycoplasma genitalium (Mgen) is a sexually transmitted infection (STI) that has an estimated prevalence in the general population of 2.3% in women and 1.1% in men aged 21–23 years. (Hilbert and Reno, 2018) A cross-sectional study conducted in a community emergency department (ED) determined that the prevalence of Mgen was 14.8% in asymptomatic female patients. (Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Treatment Guidelines, 2021) The Centers for Disease Control and Prevention (CDC) 2021 STI Treatment Guidelines recommend testing for Mgen in select circumstances. This study aims to determine what testing strategy in ED patients results in the most appropriate treatment of Mgen based on CDC recommendations. MethodsThis multicenter, retrospective, pre- and post-intervention cohort study assessed adherence to CDC recommendations for appropriate management of Mgen in ED patients. Inclusion criteria were patients at least 18 years of age discharged from one of the 15 ED sites within the health system studied who were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis (T. vaginalis), and Mgen. Subjects were excluded if they were pregnant, sexually assaulted, or had indeterminate STI results. For cohort 1, which included patients evaluated from May 2022 through July 2022, Mgen was incorporated into the standard STI testing panel. Cohort 2 consisted of patients evaluated from September 2022 through November 2022; testing for Mgen in cohort 2 was optional, and a testing algorithm based on CDC recommendations was disseminated to ED sites. The primary endpoint was the number of subjects treated appropriately for Mgen in accordance with CDC recommendations. Cohort 1 secondary endpoints included overall prevalence of Mgen in patients who presented to ED sites for STI testing and prevalence in ICD-10 code diagnosed PID. Secondary endpoints for both cohorts included baseline characteristics of patients who tested positive for Mgen. ResultsPercent appropriate treatment did not differ significantly between cohort 1 (21%) and cohort 2 (20%), (p > 0.9). However, greater than three times as many subjects were inappropriately treated for Mgen in cohort 1 when the health system studied did not adhere to current CDC Mgen testing recommendations. The overall prevalence of Mgen in ED patients who were tested for STIs was 13.1%. The prevalence of PID ICD-10 diagnosis code in patients positive for Mgen was 2.9%. Based on results of a risk factor analysis to determine if certain baseline characteristics are indicators for a positive infection with Mgen, a positive Mgen result was significantly associated with a positive result for T. vaginalis (p = 0.042). ConclusionsEvidence regarding the preferred testing strategy for Mgen is currently limited. This study demonstrates that testing all STI presenting patients for Mgen results in antibiotic overuse, so adhering to CDC testing recommendations is important. Prevalence of positive Mgen result in ED patients tested for STIs was similar to results of previously published literature. Risk factor analysis results could be used as a screening method to determine what patients should be considered for Mgen testing. Based on the results of this study, we recommend against including Mgen on the standard ED STI testing panel at this time.

The Accuracy of Predictive Analytics in Forecasting Emergency Department Volume Before and After Onset of COVID-19.

Big data and improved analytic techniques, such as triple exponential smoothing (TES), allow for prediction of emergency department (ED) volume. We sought to determine 1)which method of TES was most accurate in predicting pre-coronavirus 2019 (COVID-19), during COVID-19, and post-COVID-19 ED volume; 2)how the pandemic would affect TES prediction accuracy; and 3)whether TES would regain its pre-COVID-19 accuracy in the early post-pandemic period. We studied monthly volumes of four EDs with a combined annual census of approximately 250,000 visits in the two years prior to, during the 25-month COVID-19 pandemic, and the 14 months following. We compared the accuracy of four models of TES forecasting by measuring the mean absolute percentage error (MAPE), mean square errors (MSE) and mean absolute deviation (MAD), comparing actual to predicted monthly volume. In the 23 months prior to COVID-19, the overall average MAPE across four forecasting methods was 3.88% ± 1.88% (range 2.41-6.42% across the four ED sites), rising to 15.21% ± 6.67% during the 25-month COVID-19 period (range 9.97-25.18% across the four sites), and falling to 6.45% ± 3.92% in the 14 months after (range 3.86-12.34% across the four sites). The 12-month Holt-Winter method had the greatest accuracy prior to COVID-19 (3.18% ± 1.65%) and during the pandemic (11.31% ± 4.81%), while the 24-month Holt-Winter offered the best performance following the pandemic (5.91% ± 3.82%). The pediatric ED had an average MAPE more than twice that of the average MAPE of the three adult EDs (6.42% ± 1.54% prior to COVID-19, 25.18% ± 9.42% during the pandemic, and 12.34% ± 0.55% after COVID-19). After the onset of the pandemic, there was no immediate improvement in forecasting model accuracy until two years later; however, these still had not returned to baseline accuracy levels. We were able to identify a TES model that was the most accurate. Most of the models saw an approximate four-fold increase in MAPE after onset of the pandemic. In the months following the most severe waves of COVID-19, we saw improvements in the accuracy of forecasting models, but they were not back to pre-COVID-19 accuracies.

A-006 Evaluation of the ADVIA Centaur NT-proBNPII Assay Vs Standard-of-care Natriuretic Peptide Testing in the Emergency Department

Abstract Background The Siemens Healthineers ADVIA Centaur® NT-proBNPII (PBNPII) assay* was developed for in vitro diagnostic use in the quantitative determination of N-terminal pro-brain natriuretic peptide (NT-proBNP) in human serum and plasma (EDTA and lithium heparin) using the ADVIA Centaur XP Immunoassay System. Siemens Healthineers performed a clinical study to evaluate the ADVIA Centaur XP PBNPII assay in an Emergency Department (ED) patient population. The study also involved collection of standard-of-care (SOC) natriuretic peptide (NP) results, either NT-proBNP or BNP. Objective To compare results from the ADVIA Centaur PBNPII assay in ED populations with SOC NP results and adjudicated diagnosis of heart failure. Methods 3128 subjects were enrolled from 30 ED sites. Blood was collected at time of enrollment for subsequent ADVIA Centaur PBNPII measurement; results from SOC NP testing were obtained from chart review. Available SOC testing was performed within 24 h of enrollment draw for all except four patients. Adjudication of acute HF (de novo or worsening) or non-acute HF was determined by an independent central adjudication panel of expert clinicians. Results Of the 3128 patients in the ED study, 1646 (52.6%) had an SOC BNP test performed, 1020 (32.6%) had an SOC NT-proBNP test performed, and 462 (14.8%) had neither. Agreement between the SOC NP results and PBNPII results was assessed based on concordance using cutoffs described in heart failure guidelines that include an indeterminate zone (1). For those tested with SOC NT-proBNP, there was 94.7% concordance, 5% partial concordance (indeterminate by one assay and positive or negative by the other), and 0.3% discordance. For those tested with SOC BNP, there was 73.8% concordance, 25.5% partial concordance, and 0.7% discordance. Agreement with adjudication was virtually identical for both the PBNPII assay and SOC PBNP at 63% concordance, 17% partial concordance, and 20% discordance. For those tested with SOC BNP, there was 63% concordance, 29.5% partial concordance, and 7.5% discordance, while in this same population the PBNPII assay had 67.8% concordance, 15.7% partial concordance, and 16.5% discordance. Conclusion Upon comparison of ADVIA Centaur PBNPII assay results to SOC NP testing in an ED population, Siemens Healthineers concludes that the ADVIA Centaur PBNPII assay performs similarly to commercial natriuretic peptide assays in routine use. These results agree with publications comparing diagnostic testing of NT-proBNP and BNP for suspected heart failure (2). *Disclaimer The products/features mentioned herein are not commercially available in all countries. Their future availability cannot be guaranteed.

Use of a Medication Safety Audit and Feedback Tool in the Emergency Department Is Affected by Prescribing Characteristics.

The Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUIPPED) program developed an audit and feedback health information technology (IT) solution with the intent to replace the in-person academic detailing service provided by the program. The EQUIPPED dashboard provides emergency department (ED) providers with a personalized view of their prescribing performance. Here, we analyze the association between ED provider characteristics and viewership of the EQUIPPED dashboard, adding insight into strategies for addressing barriers to initial use. We performed a retrospective analysis of EQUIPPED dashboard viewership among four Veterans Affairs (VA) EDs. We extracted quantitative data from user interaction logs to determine evidence of dashboard use. Provider characteristics and baseline potentially inappropriate medication (PIM) prescribing rate were extracted from the VA's Corporate Data Warehouse. Logistic regression was used to examine the association between dashboard use and provider characteristics. A total of 82 providers were invited to receive audit and feedback via the EQUIPPED dashboard. Among invited providers, 40 (48.7%) had evidence of at least 1 dashboard view during the 1-year feedback period. Adjusted analyses suggest that providers with a higher baseline PIM prescribing rate were more likely to use the dashboard (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.01-1.47). Furthermore, providers at ED site D were more likely to use the dashboard in comparison to the other sites (OR: 9.99; 95% CI: 1.72-58.04) and reportedly had the highest site-level baseline PIM rate. Providers with lower PIM prescribing rates (i.e., <5%) receive communication from an integrated dashboard reminder system that they are "optimal prescribers" which may have discouraged initial attempts to view the dashboard. Site D had the highest baseline PIM rate, but further qualitative investigation is warranted to better understand why site D had the greatest users of the dashboard.

An Outcome Comparison Between Geriatric and Nongeriatric Emergency Departments

We sought to describe diagnosis rates and compare common process outcomes between geriatric emergency departments (EDs) and nongeriatric EDs participating in the American College of Emergency Physicians Clinical Emergency Data Registry (CEDR). We conducted an observational study of ED visits in calendar year 2021 within the CEDR by older adults. The analytic sample included 6,444,110 visits at 38 geriatric EDs and 152 matched nongeriatric EDs, with the geriatric ED status determined based on linkage to the American College of Emergency Physicians' Geriatric ED Accreditation program. Stratified by age, we assessed diagnosis rates (X/1000) for 4 common geriatric syndrome conditions and a set of common process outcomes including the ED length of stay, discharge rates, and 72-hour revisit rates. Across all age categories, geriatric EDs had higher diagnosis rates than nongeriatric EDs for 3 of the 4 following geriatric syndrome conditions of interest: urinary tract infection, dementia, and delirium/altered mental status. The median ED site-level length of stay for older adults was lower at geriatric EDs compared with that at nongeriatric EDs, whereas 72-hour revisit rates were similar across all age categories. Geriatric EDs exhibited a median discharge rate of 67.5% for adults aged 65 to 74 years, 60.8% for adults aged 75 to 84 years, and 55.6% for adults aged >85 years. Comparatively, the median discharge rate at nongeriatric ED sites was 69.0% for adults aged 65 to 74 years, 64.2% for adults aged 75 to 84 years, and 61.3% for adults aged >85 years. Geriatric EDs had higher geriatric syndrome diagnosis rates, lower ED lengths of stay, and similar discharge and 72-hour revisit rates when compared with nongeriatric EDs in the CEDR. These findings provide the first benchmarks for emergency care process outcomes in geriatric EDs compared with nongeriatric EDs.

Use of Real-Time Information to Predict Future Arrivals in the Emergency Department.

We aimed to build prediction models for shift-level emergency department (ED) patient volume that could be used to facilitate prediction-driven staffing. We sought to evaluate the predictive power of rich real-time information and understand 1) which real-time information had predictive power and 2) what prediction techniques were appropriate for forecasting ED demand. We conducted a retrospective study in an ED site in a large academic hospital in New York City. We examined various prediction techniques, including linear regression, regression trees, extreme gradient boosting, and time series models. By comparing models with and without real-time predictors, we assessed the potential gain in prediction accuracy from real-time information. Real-time predictors improved prediction accuracy on models without contemporary information from 5% to 11%. Among extensive real-time predictors examined, recent patient arrival counts, weather, Google trends, and concurrent patient comorbidity information had significant predictive power. Out of all the forecasting techniques explored, SARIMAX (Seasonal Autoregressive Integrated Moving Average with eXogenous factors) achieved the smallest out-of-sample the root mean square error (RMSE) of 14.656 and mean absolute prediction error (MAPE) of 8.703%. Linear regression was the second best, with out-of-sample RMSE and MAPE equal to 15.366 and 9.109%, respectively. Real-time information was effective in improving the prediction accuracy of ED demand. Practice and policy implications for designing staffing paradigms with real-time demand forecasts to reduce ED congestion were discussed.

A progress update on the implementation of a multi-faceted intervention to spread and scale bronchiolitis appropriate care in Alberta

Background: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Successful implementation of an audit and feedback (A&amp;F) intervention at the Alberta Children’s Hospital (ACH) reduced use of low-value interventions and tests for bronchiolitis. Opportunities to improve bronchiolitis management are likely also present in other urban and rural settings. This project will spread and scale the work completed at ACH to 16 sites across Alberta focusing on children under one-year diagnosed with bronchiolitis who managed both in ED and inpatient settings.&#x0D; &#x0D; Methods: Site implementation included two key aspects:&#x0D; &#x0D; Audit &amp; Feedback (A&amp;F) – review practice data, facilitated discussion with clinicians and their teams, and identify enablers and barriers to practice change.&#x0D; &#x0D; The seasonality of bronchiolitis cases (November to April) helped inform the frequency of A&amp;F feedback reports: mid-season (February) and end-of-season (April)&#x0D; Clinical dashboards are being developed within the new clinical information system – ConnectCare - that will provide teams with real-time feedback on potential practice change.&#x0D; &#x0D; &#x0D; Site Specific Implementation Plan – Resources are tailored to fit site needs including the use of posters, handouts and practice guidelines; utilization of order sets; and staff and family education resources.&#x0D; &#x0D; The bronchiolitis initiative is eligible for Continuing Medical Education accreditation through a newly developed easy-to-navigate web-based tool, My Practice Improvement – MyPI. An Education Working Group consisting of patient and family advisors was developed. Family resources included a QR code handout to a “How to suction your baby’s nose” instructional video to help parents/families care for their child at home. The HEAL handout provided links to additional resources for families. Family centred care participants were consulted on the development of a family resource: “Bronchiolitis: A roadmap from admission until discharge”.&#x0D; &#x0D; Evaluation Methods: The primary objective of the study is a 25% absolute reduction in chest radiograph use. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Return visits to the ED within 72 hours of discharge will be monitored as a balancing measure to assess potential unintended consequences of de-implementing low-value tests and interventions in the ED. The provincial rollout of ConnectCare and tableau dashboard integration will enable a broader array of tests and treatments that are used in the management of bronchiolitis to be reported. The spread and scale of this project has now engaged with ED sites in non-tertiary settings in urban and rural areas where patient demographics and resource availability could pose additional challenges. Providing education and resources for these sites is one way to ensure equitable healthcare access for all Albertans.&#x0D; &#x0D; Results: Six facilities implemented rollout from September to November 2021 with a total of 151 physicians attending the A&amp;F sessions. Chest x-ray use at sites that had a 2021 session compared to sites with a planned session in 2022 revealed a decrease after one bronchiolitis season. A difference in difference analysis between the two groups demonstrated that sites with a 2021 session had a -14.3% (95%CI -21.4 to -7.1) decrease in chest x-ray use. As of November 17, 2022, there have been 12 A&amp;F sessions attended by 255 physicians, nurses and respiratory therapists.&#x0D; &#x0D; Advice and Lessons Learned: &#x0D; &#x0D; Capacity for scale and spread intiatives should be accounted for early in planning processes. We brought on two additional medical leads to facilitate sessions in fall 2022 due to an increase in the number of sites involved. Without the additional assistance, the success of roll out may have been jeopardized.&#x0D; Flexibility is key. Several sites across the province are continuing to deal with staffing shortages and recent high volumes of influenza, RSV and COVID are putting EDs over capacity. Sites have demonstrated incredible flexibility with engagement and session availabiltiy despite these circumstances. We changed session dates to help balance workloads as some sites had ConnectCare implementation concurrent with the start of the bronchiolitis season.&#x0D;

Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study

BackgroundUntreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians’ behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations.MethodsWe purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns.ResultsTwenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine.ConclusionThe findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study

BackgroundPatients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team....

Derivation and Validation of a Brief Emergency Department-Based Prediction Tool for Posttraumatic Stress After Motor Vehicle Collision.

To derive and initially validate a brief bedside clinical decision support tool that identifies emergency department (ED) patients at high risk of substantial, persistent posttraumatic stress symptoms after a motor vehicle collision. Derivation (n=1,282, 19 ED sites) and validation (n=282, 11 separate ED sites) data were obtained from adults prospectively enrolled in the Advancing Understanding of RecOvery afteR traumA study who were discharged from the ED after motor vehicle collision-related trauma. The primary outcome was substantial posttraumatic stress symptoms at 3 months (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 ≥38). Logistic regression derivation models were evaluated for discriminative ability using the area under the curve and the accuracy of predicted risk probabilities (Brier score). Candidate posttraumatic stress predictors assessed in these models (n=265) spanned a range of sociodemographic, baseline health, peritraumatic, and mechanistic domains. The final model selection was based on performance and ease of administration. Significant 3-month posttraumatic stress symptoms were common in the derivation (27%) and validation (26%) cohort. The area under the curve and Brier score of the final 8-question tool were 0.82 and 0.14 in the derivation cohort and 0.76 and 0.17 in the validation cohort. This simple 8-question tool demonstrates promise to risk-stratify individuals with substantial posttraumatic stress symptoms who are discharged to home after a motor vehicle collision. Both external validation of this instrument, and work to further develop more accurate tools, are needed. Such tools might benefit public health by enabling the conduct of preventive intervention trials and assisting the growing number of EDs that provide services to trauma survivors aimed at promoting psychological recovery.