Emergency Department Treatment Research Articles

Recommendations for prescribing pharmacologic prevention during emergency department treatment of epileptic seizures

Recommendations for prescribing pharmacologic prevention during emergency department treatment of epileptic seizures

Exploring Social Interactions in the Context of Justice System Involvement: Perspectives of Patients and Psychiatric Nurses.

Psychiatric nurses who work with people who are involved with the justice system experience ethical and moral tension arising from their dual role (care and control). This is known to significantly affect the development of a therapeutic relationship between nurses and patients. (a) better understand how justice system involvement affects people living with mental disorders and the nurses who work with them; (b) explore the influence of judiciarization on social interactions between these actors. Grounded theory (GT) was used as the qualitative methodology for this research. Semi-structured interviews were conducted with participants. The study was carried out in three different units of a psychiatric institution: Psychiatric Intensive Care Unit, Emergency Department, and Brief Intervention Unit. A sample of 10 patients and 9 psychiatric nurses was recruited (n = 19). Theoretical sampling was used to recruit participants. We followed the iterative steps of qualitative GT analysis (open coding, axial coding, constant comparison, and modelization). Three main themes emerged from the qualitative analysis: (a) Experience of Justice System Involvement, (b) Crisis, (c) Relational Aspects and Importance of the Approach. These results will inform nurses and healthcare providers about the impacts of justice system involvement on people living with mental illness and how clinical practices can be better adapted to this population with complex health needs.

The Effects of Displaying the Time Targets of the Manchester Triage System to Emergency Department Personnel: Prospective Crossover Study.

The use of triage systems such as the Manchester Triage System (MTS) is a standard procedure to determine the sequence of treatment in emergency departments (EDs). When using the MTS, time targets for treatment are determined. These are commonly displayed in the ED information system (EDIS) to ED staff. Using measurements as targets has been associated with a decline in meeting those targets. This study investigated the impact of displaying time targets for treatment to physicians on processing times in the ED. We analyzed the effects of displaying time targets to ED staff on waiting times in a prospective crossover study, during the introduction of a new EDIS in a large regional hospital in Germany. The old information system version used a module that showed the time target determined by the MTS, while the new system version used a priority list instead. Evaluation was based on 35,167 routinely collected electronic health records from the preintervention period and 10,655 records from the postintervention period. Electronic health records were extracted from the EDIS, and data were analyzed using descriptive statistics and generalized additive models. We evaluated the effects of the intervention on waiting times and the odds of achieving timely treatment according to the time targets set by the MTS. The average ED length of stay and waiting times increased when the EDIS that did not display time targets was used (average time from admission to treatment: preintervention phase=median 15, IQR 6-39 min; postintervention phase=median 11, IQR 5-23 min). However, severe cases with high acuity (as indicated by the triage score) benefited from lower waiting times (0.15 times as high as in the preintervention period for MTS1, only 0.49 as high for MTS2). Furthermore, these patients were less likely to receive delayed treatment, and we observed reduced odds of late treatment when crowding occurred. Our results suggest that it is beneficial to use a priority list instead of displaying time targets to ED personnel. These time targets may lead to false incentives. Our work highlights that working better is not the same as working faster.

Characteristics of consecutive versus non-consecutive frequent emergency medical services transport to a single emergency department

Objective This study was to examine characteristics concerning frequent users of emergency medical services (EMS) transport by comparing patients who used EMS transport frequently for one year and those who used EMS transport for more than two years consecutively. Methods A retrospective review for frequent use of EMS transport was conducted. The patients from the fire stations that transported more than 70% of all EMS transport to the study hospital emergency department (ED) were included. The study subjects were divided into consecutive group (frequent EMS transport for ≥ two years consecutively) and non-consecutive group (frequent EMS transport for only one year). Characteristics of patients who were frequent users of EMS transport and those of all cases with EMS transport were examined. Results Of the total 205 patients and 1204 cases of frequent EMS transport, 85 (42%) patients and 755 (63%) cases were in the consecutive group. Patients in the consecutive group were more likely to have risky alcohol use, unemployed state, and medical aid type of payment for ED treatment than those in the non-consecutive group. More patients had previous experience of EMS transport to the study hospital ED in the consecutive group and the number of cases with alcohol ingestion was higher in the consecutive group. Elapsed time from EMS call to ED arrival was longer for the consecutive group. Conclusion Risky alcohol use, unemployed state, and previous experience of EMS transport were associated with consecutive and frequent use of EMS transport in frequent users of EMS transport.

Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Service and Police: Trends and Interventions

ObjectiveWe aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMSs), police, or self-transported. MethodsThis retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends. ResultsOf 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001). ConclusionsPediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.

Evaluation of medications used for opioid use disorder in emergency departments: A cross-sectional analysis of the 2020 National Hospital Ambulatory Medical Care Survey

IntroductionOpioid use disorder (OUD) is a significant health issue impacting millions in the United States (US). Medications used for OUD (MOUD) (e.g., buprenorphine, methadone, naltrexone) and medications for overdose and symptom management (e.g., naloxone, clonidine) have been shown to be safe and effective tools in clinical management. MOUD therapy in Emergency Departments (EDs) improves patient outcomes and enhances engagement with formal addiction treatment; however, provider factors and institutional barriers have created hurdles to ED-based MOUD treatment and heterogeneity in ED based OUD care. We used a nationally representative dataset, the National Hospital Ambulatory Medical Care Survey (NHAMCS) to characterize MOUD prescribing practices across patient demographics, geographic regions, payers, providers, and comorbidities in EDs. MethodsNHAMCS is a survey conducted by the US Census Bureau assessing utilization of ambulatory healthcare services nationally. Survey staff compile encounter records from a nationally representative sample of EDs. We conducted a cross-sectional study using this data to assess visits in 2020 among patients aged 18–64 presenting with an opioid overdose or OUD. We estimated the proportion of patients who had any MOUD, clonidine, or naloxone treatment and 95% confidence intervals (CI). We modeled the association between patient demographic, location, comorbidities, and provider characteristics with receipt of MOUD treatment as unadjusted odds ratios (OR) and 95% CI. ResultsThere was a weighted frequency of 469,434 patients who were discharged from EDs after being seen for OUD or overdose. Naloxone, clonidine, and buprenorphine were the most frequent treatments administered and/or prescribed for OUDs or overdose. Overall, 54,123 (11.5%, 95%CI 0–128,977) patients who were discharged from the ED for OUDs or overdose received at least one type of MOUD. Hispanic race, (OR 17.9, 95%CI 1.33–241.90) and Western region (OR43.77, 95%CI 2.97–645.27) were associated with increased odds of receiving MOUDs, while arrival by ambulance was associated with decreased odds of receiving MOUDs (OR0.01, 95%CI 0.001–0.19). Being seen by an APP or physician assistant was associated with MOUD treatment (OR 16.68, 95%CI: 1.41–152.33; OR: 13.84, 95%CI: 3.58–53.51, respectively). ConclusionOur study findings suggest that MOUD and other medications for opioid overdose are infrequently used in the ED setting. This finding was especially notable in race, geographic region, mode of arrival, and those seen by APP, underscoring the need for further study into the root causes of these disparities. Our study provides a foundational understanding of MOUD patterns, guiding future research as the landscape of OUD treatment continues to shift.

Hospital at home for elderly acute patients: a study protocol for a randomised controlled trial

IntroductionThe increasing elderly population has led to a growing demand for healthcare services. A hospital at home treatment model offers an alternative to standard hospital admission, with the potential to...

Application Value of NLR, PLR, LMR, HEART score, and POCT in Early Warning and Accurate Graded Diagnosis of High-Risk Chest Pain in Emergency Medicine

Objective: To evaluate the application value of neutrophils/lymphocytes (NLR), platelets/lymphocytes (PLR), lymphocytes/monocytes (LMR), HEART (history, electrocardiogram, age, risk factors, and troponin) score, and point-of-care testing (POCT) in the early warning and precise diagnosis of high-risk chest pain in emergency medicine. Methods: A total of 157 patients with acute chest pain who were admitted to the emergency department and chest pain treatment unit of our hospital between August 2022 and September 2023 were selected. Rapid testing of bedside myocardial markers (ultrasensitive troponin (hs-cTnI), myoglobin (MYO), creatine kinase isoenzyme (CK-MB), D-dimer (D-Dimer), and N-terminal B-type natriuretic peptide precursor (NT-proBNP)) was performed on the patients using a POCT device (ThermoKing BioMQ60proB). A HEART score was used to classify the patients into low (n = 53), intermediate (n = 59), and high-risk (n = 45) groups, and the NLR, PLR, and LMR were calculated. The NLR, PLR, and LMR values were compared among the three groups of patients, and the optimal cutoff values as well as sensitivity and specificity were determined based on receiver operating characteristic (ROC) analysis. Results: The HEART scores of patients in the low-risk, intermediate-risk, and high-risk groups were (2.72 ± 0.24), (4.75 ± 0.56), and (5.32 ± 0.73) respectively, and the differences were statistically significant (P &lt; 0.05). Compared with the low-risk group, the intermediate-risk group and high-risk group had a significantly higher NLR and PLR, and a significantly lower LMR; the high-risk group had higher NLR and PLR and lower values of LMR as compared to the other two groups, and the difference was statistically significant (P &lt; 0.05). The ROC curves suggested that the area under the curve, sensitivity, and specificity of the combined diagnosis of NLR, PLR, LMR, HEART score, and POCT were greater than those of LR, PLR, and LMR with HEART score and POCT alone. Conclusion: The combined application of NLR, PLR, LMR, HEART score, and POCT has significant application value in the early warning and precise diagnosis of emergency high-risk chest pain. It provides a more simple, easy-to-access, and efficient assessment index for the clinical prediction and treatment of emergency high-risk chest pain.

Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department

BackgroundBariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. MethodsWe conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. ResultsWe included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). ConclusionThis is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments

BackgroundAnaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs.MethodsRetrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019. Data extracted from medical records included demographic characteristics, causative agents, clinical features, treatments administered across community, ambulance or ED settings, as well as post-discharge care arrangements including provision of Adrenaline Auto-Injector (AAI) and Allergy/Anaphylaxis Action Plan (AAP).ResultsA total of 369 (107 paediatric and 262 adult) ED presentations were identified. A total of 94 (36%) adult and 46 (43%) paediatric patients received pre-hospital adrenaline, with a further 91 (35%) adult and 29 (27%) paediatric patients receiving a dose of adrenaline in the ED. The most commonly administered treatment in ED were corticosteroids, given to 157 (60%) adult and 55 (51%) paediatric patients. Among those requiring an AAI for discharge, 123/210 (59%) adult and 57/91 (63%) of paediatric patients left hospital with an AAI. In contrast, among those requiring an allergy/anaphylaxis action plan (AAP) on discharge, 61/206 (30%) adult and 30/90 (33%) of paediatric patients left hospital with one. Factors associated with an increased likelihood of receiving AAI on discharge in paediatric and adult patients included receipt of any adrenaline, receipt of two or more doses of adrenaline, and longer duration of hospital stay. Adults presenting within business hours were more likely to be discharged with AAI, but no such difference was observed for paediatric patients. Similar findings were evident for provision of AAP on discharge.ConclusionThese findings demonstrate the need to improve assessment and treatment in the ED. In particular, the observed large variability in provision of AAI and AAP on discharge presents opportunities to explore strategies to improve awareness and provision of these critical components of post-discharge care.

Impact of a Strategy for Improving Early Management of Acute Pain in the Pediatric Emergency Department.

The objective of this study was to measure the impact of an intervention on pain treatment in a pediatric emergency department (ED). The application of interventions to improve pain management in DE has demonstrated diverse effects so far, most of them successful. This is a quasi-experimental before-and-after, longitudinal, prospective study.Patients were collected between January 2020 and December 2021. Principal outcome was the number of patients with moderate or severe pain who received analgesia before 30 minutes to the ED arrival. The intervention consisted of several training sessions for nursing staff, pediatricians, and trauma physicians. A total of 515 patients were enrolled, 230 during preintervention period and 285 during postintervention period. The percentage of patients receiving analgesia before 30 minutes increased from 24% to 29% and before 60 minutes increased from 31% to 42%. Time to analgesia administration decreased from 43 to 39 minutes.Only 254 patients (49%) received analgesia at some point during their stay in the ED, 137 (26.6%) before 30 minutes and 193 (37.5%) before 60 minutes. The probability of receiving analgesia was greater in patients seen by a pediatrician rather than an orthopedist (59%-37%). Metamizole was the most commonly used drug (48%), followed by ibuprofen and acetaminophen. The application strategies to enhance early pain treatment in the ED can improve analgesia administration. Training strategies aimed at healthcare personnel working in the ED can change the way they work and achieve clear benefits for the patient. The treatment of pain in the ED should begin as soon as possible, and in this objective, the involvement of the nursing staff is a priority, because they are the professional who has the best opportunity for the detection and treatment of pain from the moment of triage.

Management of acute exacerbations of COPD in the emergency department and its associations with clinical variables.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause for emergency department (ED) visits. Still, large scale studies that assess the management of AECOPD in the ED are limited. Our aim was to evaluate treatment characteristics of AE-COPD in the ED on a national scale. A prospective study as part of the COPD Israeli survey, conducted between 2017 and 2019, in 13 medical centers. Patients hospitalized with AECOPD were included and interviewed. Clinical data related to their ED and hospital stay were collected. 344 patients were included, 38% females, mean age of 70 ± 11years. Median (IQR) time to first ED treatment was 59 (23-125) minutes and to admission 293 (173-490) minutes. Delayed ED treatment (> 1h) was associated with older age (p = 0.01) and lack of a coded diagnosis of COPD in hospital records (p = 0.01). Long ED length-of-stay (> 5h) was linked with longer hospitalizations (p = 0.01). Routine ED care included inhalations of short-acting bronchodilators (246 patients, 72%) and systemic steroids (188 patients, 55%). Receiving routine ED care was associated with its continuation during hospitalization (p < 0.001). In multivariate analysis, predictors for patients not receiving routine care were obesity (adjusted odds ratio 0.5, 95% CI 0.3-0.8, p = 0.01) and fever (AOR 0.3, 95% CI 0.1-0.6, p < 0.01), while oxygen saturation < 91% was an independent predictor for ED routine treatment (AOR 3.6, 95% CI 2.1-6.3, p < 0.01). Our findings highlight gaps in the treatment of AECOPD in the ED on a national scale, with specific predictors for their occurrence.

Emergency Department Treatment of Psychogenic Non-epileptic Seizures: A Retrospective Chart Review (P7-1.005)

Emergency Department Treatment of Psychogenic Non-epileptic Seizures: A Retrospective Chart Review (P7-1.005)

Emergency Department Treatment of Alcohol-associated Seizures in Detroit: A Multicenter Retrospective Study (S24.009)

Emergency Department Treatment of Alcohol-associated Seizures in Detroit: A Multicenter Retrospective Study (S24.009)

Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study.

Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

Outcomes of Chengdu Pediatric Emergency Triage Criteria: A Retrospective Study of 198,628 Pediatric Patient Records.

BACKGROUND The Chengdu pediatric emergency triage criteria were developed at our hospital and consist of 4 triage levels: immediate treatment (level 1), treatment within 10 min (level 2), treatment within 30 min (level 3), and treatment within 240 min (level 4). This study aimed to evaluate outcomes from the levels 1 to 4 of this triage criteria. MATERIAL AND METHODS A self-designed survey form was used to collect pediatric Emergency Department (ED) patients' general data, including age, sex, and chief concern, and clinical data, including triage level, whether the patient had died, and whether the patient was admitted to our hospital. A total of 198,628 patient records that were triaged during January to May 2022 using Chengdu pediatric emergency triage criteria were included in this retrospective study. The numbers of patients triaged to levels 1, 2, 3, and 4 were 128, 1164, 14,560, and 182,776, respectively. RESULTS Statistically significant differences were found in waiting time for treatment, hospital admission rates, admission conversion rates, and case mix index at admission under different triage levels. The higher the triage priority level, the shorter the waiting time for ED treatment, higher the hospital admission and admission conversion rates, and higher case mix index value. CONCLUSIONS The Chengdu pediatric emergency triage criteria developed and applied within our hospital appears to be characterized by good clinical validity. Equipped with this triage criteria, triage nurses are more capable of determining the severity and emergency of the pediatric ED patients' health conditions and effectively triaging the patients.

Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients.

Hypertension (HTN) is common in discharged emergency department (ED) patients, yet the short-term outcomes of treating HTN at ED discharge are unclear. This study aimed to investigate whether emergency physician (EP) prescription of oral antihypertensive therapy at ED discharge for hypertensive patients is associated with a decreased 30-day risk of the severe adverse events (AEs), death, and revisits to the ED. We conducted an observational cohort study assessing the 30-day outcomes of discharged ED patients with HTN, comparing outcomes based on whether antihypertensive therapy was prescribed. All discharged adult ED patients from an eight-hospital system with a diagnosis of HTN from January 2016 to February 2020 were screened, and consisted of a mix of suburban and urban patients with broad ethnic and socioeconomic backgrounds. Patients were categorized into the treatment group if they received a prescription for antihypertensive medication at ED discharge. The primary outcome was severe composite AEs from HTN (aortic catastrophe, heart failure, myocardial infarction, hemorrhagic and ischemic stroke, or hypertensive encephalopathy) within 30 days of ED discharge. The secondary outcomes were death or ED revisit over the same period. The study sample consisted of 93,512 ED visits; 57.5% were female, and mean age was 59.3 years. 4.7% of patients were prescribed antihypertensive treatment at ED discharge. Within 30 days, 0.7% of patients experienced an AE, 0.1% died, and 15.2% had an ED revisit. The treatment group had significantly lower odds of AE (adjusted odds ratio [aOR]: 0.224, 95%CI 0.106-0.416, p<0.001), and ED revisits (aOR: 0.610, 95%CI 0.547-0.678, p<0.001), adjusting for age, race, degree of HTN, ED treatment for elevated HTN, Elixhauser comorbidity index, and heart failure history. There was no difference in odds of death 30 days after discharge. Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.

A mapping review of interventions to address patients who frequently seek care in the emergency department

BackgroundThe high utilization of acute care services, particularly emergency departments (ED), continues to be a significant concern for healthcare providers. Numerous approaches have been studied to meet the care needs of patients who frequently seek care in the ED; however, there is no comprehensive review of the current literature base. As such, a current understanding of the interventions initiated within the ED to address the needs of frequent users is required. This mapping review had three objectives: identify the characteristics associated with the need to frequently seek care in the ED; identify interventions implemented to address the needs of this population; and identify gaps in the current evidence base.MethodsA knowledge map was created by scoping the literature to identify characteristics associated with frequent ED use and interventions implemented to address frequent use. Then, a literature search was conducted to determine what has been implemented by EDs to reduce frequent ED use. The literature was searched from 2013 to January 2023. MeSH terms and keywords were used to identify relevant studies. Studies implementing an intervention for those with characteristics associated with frequent ED use and reporting on ED use were included.ResultsTwenty-three (23) controlled trials and 35 observational studies were included. The most common populations were older adults, those with chronic conditions, and generic “frequent users”. No studies assessed Indigenous Peoples or racial minorities, and few assessed patients with a disability or patients experiencing homelessness. The most common interventions were referrals, care plans, case management, care coordination, and follow-up phone calls. Most studies reported ED revisits, hospitalization, costs, length-of-stay, or outpatient utilization. Few assessed patient or staff perspectives. About one-third of studies (n = 24) reported significant reductions in ED revisits.ConclusionsSimilar interventions, mainly focused on care coordination and planning, have been implemented to address frequent use of the ED. There are still significant gaps in the populations that have been studied. Efforts now must be undertaken to study more diverse populations whose care needs are not being met elsewhere and thus frequent the ED often.

How well do ED physician practices align with the CAEP acute atrial fibrillation checklist for stroke prevention and disposition?

Acute atrial fibrillation (AF)/flutter (AFL) is a common emergency department (ED) presentation. In 2021, an updated version of CAEP's Acute AF/AFL Best Practices Checklist was published, seeking to guide management. We assessed the alignment with and safety of application of the Checklist, regarding stroke prevention and disposition. This health records review included adults presenting to two tertiary care academic EDs between January and August 2022 with a diagnosis of acute AF/AFL. Patients were excluded if their initial heart rate was < 100 or if they were hospitalized. Data extracted included: demographics, CHADS-65 score, clinical characteristics, ED treatment and disposition, and outpatient prescriptions and referrals. Our primary outcome was the proportion of patient encounters with one or more identified safety issues. Each case was assessed according to seven predetermined criteria from elements of the CAEP Checklist and either deemed "safe" or to contain one or more safety issues. We used descriptive statistics with 95% confidence intervals. 358 patients met inclusion criteria. The mean age was 66.9years, 59.2% were male and 77.4% patients had at least one of the CHADS-65 criteria. 169 (47.2%) were not already on anticoagulation and 99 (27.6%) were discharged home with a new prescription for anticoagulation. The primary outcome was identified in 6.4% (95% CI 4.3-9.5) of encounters, representing 28 safety issues in 23 individuals. The safety concerns included: failure to prescribe anticoagulation when indicated (n = 6), inappropriate dosing of a direct oral anticoagulant (DOAC) (n = 2), inappropriate prescription of rate or rhythm control medication (n = 9), and failure to recommend appropriately timed follow-up for new rate control medication (n = 11). There was a very high level of ED physician alignment with CAEP's Best Practices Checklist regarding disposition and stroke prevention. There are opportunities to further improve care with respect to recommendation of anticoagulation and reducing inappropriate prescriptions of rate or rhythm medications.

Impact of a Coordinated Sepsis Response on Time to Treatment in a Pediatric Emergency Department.

Sepsis is responsible for 75 000 pediatric hospitalizations annually, with an associated mortality rate estimated between 11% and 19%. Evidence supports the use of timely fluid resuscitation and antibiotics to decrease morbidity and mortality. Our emergency department did not meet the timeliness goals for fluid and antibiotic administration suggested by the 2012 Surviving Sepsis Campaign. In November 2018, we implemented a sepsis response team utilizing a scripted communication tool and a dedicated sepsis supply cart to address timeliness barriers. Performance was evaluated using statistical process control charts. We conducted observations to evaluate adherence to the new process. Our aim was to meet the Surviving Sepsis Campaign's timeliness goals for first fluid and antibiotic administration (20 and 60 minutes, respectively) within 8 months of our intervention. We observed sustained decreases in mean time to fluids. We also observed a shift in the proportion of patients receiving fluids within 20 minutes. No shifts were observed for timely antibiotic administration. The implementation of a dedicated emergency department sepsis response team with designated roles and responsibilities, directed communication, and easily accessible supplies can lead to improvements in the timeliness of fluid administration in the pediatric population.