Emergency Department Presentation Research Articles

Antenatal counselling at the cusp of viability and parental decision-making in the zone of parental discretion: A cohort study.

Safer Care Victoria updated a clinical guideline on extreme prematurity in 2020, reducing the threshold for offering resuscitation from 23 to 22 weeks gestation. The zone of parental discretion is the interval of shared decision-making between parents and doctors regarding resuscitation decisions. It is especially relevant at this periviable gestation. Our study aimed to establish current practices in antenatal counselling and steroid administration at this cusp of viability, and examine the decisions made during the zone of parental discretion. Single centre retrospective cohort study. Sixteen thousand three hundred fifty-four admissions and emergency department presentations between January 2021 and July 2023 were retrieved from Birthing Outcomes System (BOS) and patient details were imported and manually reviewed on Microsoft Excel, with particular note to the gestation at admission/emergency department presentation and duration of admission. Eighty-seven patients were identified as present in the hospital between 21 + 0 and 22 + 6 weeks gestation. These 87 scanned records on Clinical Patient Folder (CPF) were then manually reviewed to identify if antenatal counselling occurred during this window. Thirty-six patients were included who received antenatal counselling between 21 + 0 and 22 + 6 weeks gestation (the remaining patients did not receive antenatal counselling during this window), and relevant data was subsequently extracted from the scanned medical record and analysed using SPSS software (IBM SPSS Statistics 29). Thirty-six women received antenatal counselling between 21 + 0 and 22 + 6 weeks. 58% decided on full resuscitation and 39% opted for comfort care if their infant was to be born between 22 + 0 and 22 + 6 weeks. All but one baby born premature were exposed to steroids, with 83.3% receiving a full course. Twenty-eight infants (62.2%) were fully steroid loaded at the time of delivery. In those fully steroid loaded, 31.1% of the time steroids were initiated prior to transfer, 50% of the time deferred until neonatal review and a decision regarding the resuscitation status of the baby, and on one occasion requested by the neonatologist before counselling. Patients at risk for premature birth who attended our hospital at the cusp of viability were generally counselled about the opportunity for resuscitation between 22 + 0 and 22 + 6 weeks gestational age, and offered steroids. Further studies are required to establish whether the content of antenatal counselling, and the timing of steroids, are consistent in this population.

Convergence insufficiency as a predictor of poor prognosis after acute mild traumatic brain injury

BackgroundMild traumatic brain injury (mTBI) is becoming a more common emergency department (ED) presentation. Towards this end, many types of testing in the acute setting are being investigated. One of these is screening for convergence insufficiency (CI) symptoms. These are common problems reported by patients with mTBI, but such oculomotor testing is rarely performed in the ED.ObjectiveTo assess the feasibility of convergence insufficiency screening in the ED and investigate whether CI is associated with adverse events such as post-concussive symptoms or hospital admission.MethodsWritten informed consent was obtained from patients age 18 years or older who experienced a mild head injury from any mechanism resulting in an mTBI. Patients underwent screening for CI symptoms using a standardized instrument of 15 questions, known as the convergence insufficiency symptom survey (CISS), with responses based on the Likert scale. These data were correlated to outcomes of hospital admission, occurrence of post-concussive symptoms, and 30-day hospital re-admission.ResultsA total of 116 patients were prospectively enrolled, of which 58 were male. The median age was 31 years, with a range of 18 to 95 years of age. The median CISS score was 13, with an interquartile range (IQR) of 6 to 21 and an overall range of 0 to 53. Females presented with a median CISS score of 14, which was higher compared to the male median score of 10. The higher the CISS score, the more likely the patient was to be admitted to the hospital (p = 0.0378), develop symptoms of post-concussive syndrome at 30-day follow up (p = 0.0322), and be readmitted within 30 days (p = 0.0098).ConclusionsScreening for CI symptoms using the CISS can be a solid adjunct in the evaluation of mTBI in the ED. The CISS is easy and fast to administer, and it is a useful tool to stratify patients in terms of who is at the highest risk of developing complications related to the mTBI.

Implementing a pathway for patients diagnosed with cancer in the emergency department.

Patients diagnosed with cancer or suspected cancer during an emergency department (ED) presentation are often signposted back to their GP for urgent referral to cancer services. However, this can result in delays in patients receiving specialist support, confirmation of diagnosis and, vitally, starting treatment. A quality improvement initiative that aimed to address these issues through the introduction of an ED suspected cancer diagnosis pathway was implemented by the acute oncology service in two EDs in Oxford University Hospitals NHS Foundation Trust in April 2023. Data collected during the first year of implementation of the pathway show there has been a significant increase in the numbers of patients meeting the NHS England 62-day referral to treatment standard and in the numbers of patients receiving support from an acute oncology named cancer clinical nurse specialist from the point of discharge from the ED. This article details the initiative, which is ongoing, and shares some of the results from the first year of data collection.

Estimating the impact of the COVID-19 vaccination programme in Ireland: December 2021-March 2023

Abstract Background In Autumn 2023, COVID-19 booster vaccines were offered to all those aged ≥50 years in Ireland. There was concern that vaccine fatigue would impact uptake. We aimed to quantify the direct impact of the COVID-19 vaccination programme on averted outcomes in individuals aged ≥50 years, during a period of Omicron variant dominance, to inform vaccination strategy and public health communication. Methods We conducted a retrospective observational study from December 2021 to March 2023 in Ireland. We considered as averted outcomes symptomatic SARS-CoV-2 presentations to primary care, emergency department (ED) presentations, hospitalisations, intensive care unit (ICU) admissions and deaths due to COVID-19. We used an adapted formula from other vaccine impact published studies, including national data on notified outcomes, vaccine coverage data and vaccine effectiveness (VE) estimates, sourced from the WHO’s live systematic VE review, to estimate the count and prevented fraction of outcomes in ≥ 50-year-olds averted by the COVID-19 vaccination programme. The number of expected outcomes in the absence of vaccination was calculated by summing the counts of outcomes observed and outcomes averted. Results Between December 2021 and March 2023, the COVID-19 vaccination programme averted 48,551 symptomatic presentations to primary care (36% of expected), 9,517 ED presentations (53% of expected), 102,160 hospitalisations (81% of expected), 3,303 ICU admissions (89% of expected) and 15,985 deaths (87% of expected). Conclusions During Omicron dominance, the COVID-19 vaccination programme averted symptomatic and severe outcomes, including deaths due to COVID-19, underscoring the benefits of COVID-19 vaccination. In the context of vaccine fatigue emerging as an important public health issue in Ireland and internationally, these findings can inform future COVID-19 booster vaccination programmes and communication about the reason for and importance of COVID-19 vaccination. Key messages • The COVID-19 vaccination programme in Ireland prevented illness and death in people aged ≥50-years. Vaccination therefore protected population health and the healthcare system. • These findings can be used to inform future COVID-19 vaccination policies, planning for winter, pandemic preparedness and communisation about the importance of ongoing COVID-19 vaccination programmes.

Growth differentiation factor-15 and 5-years cardiovascular risk in chest pain patients presenting to the emergency department: a multicenter cohort study

Abstract Background Growth differentiation factor 15 (GDF-15) has been explored as a prognostic biomarker in multiple disease entities, including ischemic heart disease and heart failure (HF), but its role as a prognostic marker in chest pain patients presenting to the emergency department (ED) is unknown. Purpose To investigate the association between GDF-15 and 5-year all-cause mortality, cardiovascular mortality, and major adverse cardiac events (MACE), and to evaluate its prognostic incremental value. Methods Patients presenting to the ED with acute chest pain were prospectively enrolled in an international multicenter diagnostic study. GDF-15 concentrations were measured in a blinded fashion upon ED presentation. Follow-ups were performed at 3 months, 1-, 2- and 5-years. MACE was defined as the composite of cardiovascular mortality, acute myocardial infarction, stroke, and HF rehospitalization. Associations between GDF-15 and each prognostic outcome were modeled using multivariable Cox proportional hazard regression fitting restricted cubic splines to continuous variables. The magnitude of the effect of each GDF-15 unit change on multivariable-adjusted models was assessed graphically using dose-response plots. To compute an HR for the dose-response plots we chose a GDF-15 value of 1200 pg/mL as a reference value as this has been chosen in previous literature1. For the restricted cubic splines three knots were used. The added prognostic value of GDF-15 was evaluated by the increase in the C-statistic between a base and an extended model and the fraction of new information (FNI) provided by GDF-15. Results A total of 4779 chest pain patients had baseline GDF-15 values available. The median age was 61 [48-74] and 33% were female. Higher GDF-15 levels were more strongly associated with heart failure, kidney dysfunction, older age, hypertension, diabetes and coronary artery disease. GDF-15 was independently associated with 5-years all-cause mortality, cardiovascular mortality and MACE (Figure). When adding GDF-15 to a rich-for-prior-information base model which included age, sex, cardiovascular risk factors, creatinine, cardiac troponin and NT-proBNP, GDF-15 provided relevant incremental prognostic discrimination for 5-years all-cause death and cardiovascular death. (Table). Conclusions In chest pain patients presenting to the emergency department, GDF-15 concentration on admission was associated with 5-years all-cause mortality, cardiovascular mortality, and MACE. In addition, it provided relevant incremental prognostic information when added on top of troponin and NT-proBNP, the two current prognostic gold standard biomarkers.FigureTable

Remote monitoring and prioritisation for patients awaiting transcatheter aortic valve implantation safely mitigates longer waiting times

Abstract Background • The UK National Health Service (NHS) faces an unprecedented backlog of over 400,000 patients awaiting critical cardiac procedures, incurring thousands of excess deaths (1). • Longer waiting times to transcatheter aortic valve implantation (TAVI) can increase rates of unplanned hospitalisation and death (2). • Remote patient monitoring (RPM) can improve cardiovascular clinical outcomes (3), but its effectiveness in detecting and managing TAVI waiting list deterioration is untested. Purpose 1. Measure the systemic increase in waiting time to TAVI 2. Determine if RPM and prioritisation: · Is acceptable to patients · Detects clinical deterioration · Mitigates the expected increase in adverse events associated with longer waiting times · Does not unfairly disadvantage patients who are not prioritised Methods • We performed an observational cohort study including all patients awaiting TAVI at one UK regional centre between 24th April and 15th November 2023. • Patients were supported to complete an online or telephone-based weekly symptom questionnaire. • Responses were monitored by non-specialist nurses staffing a 'hub', with rule-based escalation to the TAVI team, who could prioritise treatment (Figure 1). • A historical control cohort who did not receive RPM was identified, as sequential unselected patients on the TAVI waiting list in reverse order, from 24th April 2023 to 1st January 2023. This cohort was propensity score-matched to adjust for age, sex, ethnicity and comorbidities. • Waiting time was defined as the date difference between a patient being placed on the waiting list and TAVI completion. • We defined patient acceptability as >80% engagement with at least one symptom questionnaire. • Sensitivity was calculated as the percentage of escalations to the TAVI Consultant resulting in prioritisation. • Kaplan-Meier survival analysis was performed for the primary endpoint of adverse events, defined as emergency department presentation, unplanned hospitalisation or death. Results • The median waiting time to TAVI increased by one month (104 days versus 75 days, p<0.001). • There was 99% (200/202) engagement with RPM • Despite the increased waiting time, there was no significant difference in rate of adverse events between the propensity score-matched RPM and historical control groups (12.5% versus 13.7%, p=0.86) (Figure 2) • 87% (27/31) of escalations to the TAVI Consultant resulted in treatment prioritisation • There was a non-significant difference in median waiting time between prioritised and non-prioritised patients during the study period, but with no clinical consequence to the delay (97 versus 120 days, p=0.16). Conclusions • An RPM pathway can detect patient deterioration on TAVI waiting lists with high sensitivity • RPM-based prioritisation for patients awaiting TAVI can mitigate the increased risk of adverse events associated with longer waiting times, without unfairly disadvantaging non-prioritised patients.Figure 1.RPM pathwayFigure 2

The prevalence and impact of changes in the severity of secondary TR during hospitalization in acute heart failure

Abstract Background Secondary tricuspid regurgitation (TR) is a prevalent entity in patients hospitalized for acute heart failure (AHF), and concomitant moderate or severe TR at admission has been demonstrated to be associated with a poor prognosis. However, no study has described the trajectories of the severity of secondary TR during admission, and the prognostic implications of changes in the severity of secondary TR. Purpose This study aimed to investigate the dynamism of secondary TR observed during hospitalization due to worsening heart failure, and its prognostic impact in patients with AHF. Methods A post-hoc analysis of 1,061 consecutive patients hospitalized with AHF was performed, enrolled in the prospective, multicenter Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure (REALITY-AHF). Patients included in the study underwent a comprehensive echocardiographic examination within 24 hours of admission and again prior to discharge. Patients were divided into four groups based on the TR severity at admission and discharge: none to mild TR at both admission and discharge (no/no group), moderate to severe TR at admission but improved to none to mild TR at discharge (resolution group), none to mild TR at admission but moderate to severe TR at discharge (worsening group), and moderate to severe TR at both admission and discharge (persistent group). The primary endpoint was the composite of 1-year all-cause mortality and HF re-hospitalization after discharge. Results The no/no, resolution, worsening, and persistent groups included 479 (45%), 275 (26%), 85 (8%), and 222 patients (21%), respectively. The no/no group and the resolution group had significantly lower tricuspid regurgitant pressure gradients prior to discharge compared to the worsening and persistent groups (P<0.001). Also, right ventricular dysfunction evaluated at discharge, defined by tricuspid annular plane systolic excursion <17 mm, was more prevalent in the worsening (65.7%) and persistent groups (66.4%) compared to the no/no (43.7%) and resolution (53.2%) groups (P<0.001). Compared to the no/no group, the worsening and persistent groups, but not the resolution group, were associated with a higher incidence of the primary endpoint (Log-rank: P<0.001). This association remained significant in an adjusted Cox regression analysis, with the worsening group (hazard ratio: 1.48, 95% confidence interval [CI]: 1.01–2.20) and persistent group (hazard ratio: 1.35, 95% CI: 1.01–1.83) independently associated with the primary endpoint, but not the resolution group (hazard ratio: 1.10, 95% CI: 0.81–1.49). Conclusions In patients hospitalized for AHF, the severity of secondary TR is dynamic, and changes in the severity of TR are significantly associated with prognosis. Our study results underscore the importance of repetitive evaluation of TR in hospitalized patients with AHF.

Can a chest pain virtual ward be used to safely manage patients with low-risk acute coronary syndrome?

Abstract Background Acute coronary syndrome (ACS) accounts for approximately 2-6% of emergency department (ED) presentations and contributes at least 20% of the overall acute hospital admissions(1-3). Patients presenting with low-risk ACS may be suitable for remote monitoring(4) while awaiting angiogram in chest pain virtual ward(CPVW) thereby improving patient flow and resource utilisation. Purpose We aimed to assess outcomes for patients with low-risk ACS admitted in a district general hospital with a view to establish an onboarding pathway for CPVW whilst ensuring a safe monitoring without effecting the readmission rate or all-cause mortality. Methods We retrospectively analysed the Myocardial Ischaemia National Audit Project (MINAP) registry of from March 2022 to April 2023 for patients who presented to ED with a diagnosis of confirmed ACS. Patients were stratified into low-risk (GRACE score <140, HEART score <4, non-dynamic ECG, non-dynamic troponin, without ongoing chest pain), all other patients were deemed intermediate-to-high-risk ACS. Baseline demographics, the total length of acute admission days, waiting time before and after coronary investigation ,adverse events (escalation of therapy, death)whilst awaiting for invasive inpatient angiogram were calculated. The primary endpoint was 30-day readmission and all-cause mortality. Results 1077 patients were coded as ACS diagnosis in ED. 561(52.1%) had a confirmed diagnosis of ACS. Data to allow stratification was available for 538 patients, included in final analysis. 377(70.1%) were male with a mean age of 66.8 ± SD 13.1 years. A significant number of patients had other comorbidities, including hypertension (66.1%), diabetes (45.3%), hyperlipidaemia (51.3%), and previous history of IHD (46.5%). Total number of patients stratified into low-risk ACS was 55(10.2%), intermediate-to-high-risk group contained 483(89.8%) patients. The median total-length-of-stay (LOS) for low-risk ACS patients was 4 days(IQR 2-7), waiting time to have an inpatient angiogram was 3 days(IQR 0-5), and discharge time post-angiogram was 1 day(IQR 0-2). 4 patients(7.3%) in low-risk cohort required CCU admission for GTN infusion due to ongoing chest pain, among them 3 patients(5.5%) had abnormal coronary angiogram. 5 patients(9.1%) in low-risk cohort were readmitted due to chest pain post-angiogram and no patients had 30-days or 1-year all-cause mortality. The result depicts 51 patients from low-risk cohort would have been eligible for CPVW reducing the LOS from median 4 days to 1-2 days, this is a saving of 102-153 acute bed days per year. Assuming the costing of a bed day is £320 this equates to £32,640 - £48,960 cost saving without any adverse outcomes. Conclusion Our data suggests that there is a large cost saving with minimal risk in managing patients with low-risk ACS via a CPVW. This pathway of management is likely to have benefit in patient flow and resource utilisation in our district general hospital trust.Comparison of different ACS cohortsCPVW flow-diagram

Chronic Coronary Syndromes with/without obstructive coronary arteries: are there differences in ongoing chest pain?

Abstract Background Stable coronary artery disease (CAD) is the archetype chronic coronary syndrome, clinically manifesting as angina with obstructive CAD on angiography and managed via evidence-based guidelines. In contrast, patients with Angina with Non-Obstructive Coronary Arteries (ANOCA) are often diagnosed with ‘non-specific chest pain’ and not appropriately managed. Purpose To compare the Seattle Angina Questionnaire (SAQ) responses and 3-year rates of chest pain hospital presentations in patients with ANOCA compared to Stable CAD. Methods Consecutive angina patients undergoing elective coronary angiography enrolled in the CADOSA (Coronary Angiogram Database of South Australia) Registry between 2012-18 were included. Consenting patients participated in a longitudinal health status assessment utilising the SAQ. In-hospital clinical data was extracted from CADOSA and mortality and hospitalisation data over 12-months was extracted via administrative records. Results Of 6,372 consecutive patients undergoing elective angiography for the investigation of chest pain 2,287 had ANOCA and 4,085 Stable CAD. ANOCA patients were younger (61±11 vs 66±11, p<0.05) and more often female (59% vs 27%, p<0.05) compared to Stable CAD. The SAQ health status assessment was completed at baseline, 1 and 12-months for 377 patients (ANOCA n=156, Stable CAD n=221). At 12-month follow-up, there were no differences in SAQ scores amongst all domains (physical limitation- 92±16 vs 92±15, angina stability- 64±25 vs 62 ±24, angina frequency- 91±17 vs 92±16, treatment satisfaction- 94±13 vs 94±13 and quality of life- 78±22 vs 81±21) between ANOCA and Stable CAD, all p>0.05. However, in the 12-month follow-up, ANOCA patients were less likely to have a chest pain hospital emergency department presentation (10% vs 15%, p<0.001) or admission (6% vs 12%, p<0.005) compared to the Stable CAD cohort. Conclusion Although patient-reported outcomes were identical between Stable CAD and ANOCA patients, the latter were less likely to present to emergency department or be admitted to hospital than their Stable CAD counterparts, reflecting the clinical nihilism encountered in the ANOCA patient journey.

The relationship of clinical presentation, d-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected pulmonary embolism

Abstract Introduction Elevated D-dimer levels can be detected in patients with pulmonary embolism (PE), but also in patients with the disease caused by the novel coronavirus (COVID-19). Aims To investigate relationship between clinical presentation, D-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected PE. Material and methods This retrospective study included 609 consecutive outpatients (mean age 68±15 years, 50% female) who underwent computed tomography pulmonary angiography for suspected PE from 2021 to 2023. By reviewing electronic databases, clinical and laboratory data were collected, as well data on previously documented SARS-CoV-2 infection. Results PE was confirmed in 130 (21%) patients who had higher D-dimer values than patients without PE (p<0.001). Patients with previous COVID-19 had significantly higher D-dimer values compared to those without prior COVID-19, but only during the first 8 months from infection to pulmonary angiography (Figure, upper panel). Clinical probability of PE, as indicated by Geneva score [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.55 – 3.58)], and age-adjusted D-dimer (OR 4.52, 95%CI 1.58 – 12.90) were independently associated with PE, while previous COVID-19 was not. Main clinical reasons for emergency department presentation are shown in Figure (bottom panel). In 45/609 (7.4%) patients evaluated primarily for elevated D-dimer, the prevalence of COVID-19 in the previous 6 months was higher in those with PE compared to those without PE (100% vs. 49%, p=0.019). Conclusion Within 8 months of infection, patients with a history of COVID-19 had higher D-dimer levels than those without COVID-19. Age-adjusted D-dimer and standard clinical probability scores retained their predictive power in outpatients with suspected PE, regardless of COVID-19 history.

Early prediction of sepsis in emergency department patients using various methods and scoring systems.

Early recognition of sepsis, a common life-threatening condition in intensive care units (ICUs), is beneficial for improving patient outcomes. However, most sepsis prediction models were trained and assessed in the ICU, which might not apply to emergency department (ED) settings. To establish an early predictive model based on basic but essential information collected upon ED presentation for the follow-up diagnosis of sepsis observed in the ICU. This study developed and validated a reliable model of sepsis prediction among ED patients by comparing 10 different methods based on retrospective electronic health record data from the MIMIC-IV database. In-ICU sepsis was identified as the primary outcome. The potential predictors encompassed baseline demographics, vital signs, pain scale, chief complaints and Emergency Severity Index (ESI). 80% and 20% of the total of 425 737 ED visit records were randomly selected for the train set and the test set for model development and validation, respectively. Among the methods evaluated, XGBoost demonstrated an optimal predictive performance with an area under the curve (AUC) of 0.90 (95% CI: 0.90-0.91). Logistic regression exhibited a comparable predictive ability to XGBoost, with an AUC of 0.89 (95% CI: 0.89-0.90), along with a sensitivity and specificity of 85% (95% CI: 0.83-0.86) and 78% (95% CI: 0.77-0.80), respectively. Neither of the five commonly used severity scoring systems demonstrated satisfactory performance for sepsis prediction. The predictive ability of using ESI as the sole predictor (AUC: 0.79, 95% CI: 0.78-0.80) was also inferior to the model integrating ESI and other basic information. The use of ESI combined with basic clinical information upon ED presentation accurately predicted sepsis among ED patients, strengthening its application in ED. The proposed model may assist nurses in risk stratification management and prioritize interventions for potential sepsis patients, even in low-resource settings.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 2: Complications, postrevascularization care, and quality improvement.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the later phases of inpatient care are reviewed. Published descriptions and validation of clinical pharmacist roles specific to the acute management of STEMI are limited. This high-risk period from presentation through revascularization, stabilization, and hospital discharge involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. A companion article reviewed STEMI pharmacotherapy from emergency department presentation through revascularization. Herein we complete the pharmacotherapy review for the STEMI patient across the inpatient phases of care, including the management of peri-infarction complications with vasoactive and antiarrhythmic agents, considerations for postrevascularization antithrombotics, and assessments of supportive therapies and secondary prevention. Key guideline recommendations and literature developments are summarized from the clinical pharmacist's perspective alongside suggested pharmacist roles and responsibilities. Considerations for successful hospital discharge after STEMI and pharmacist involvement in associated institutional quality improvement efforts are also provided. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population and call for further research delineating pharmacists' impact on patient and institutional STEMI outcomes.

The Epidemiology of Pediatric Shoulder Dislocations in the United States.

Shoulder dislocations are the most common of all major joint dislocations and are a frequent cause of emergency department (ED) presentations. While the epidemiology of shoulder dislocations has been characterized in adults, it has not yet been done for children in the United States. The primary goal of this study was to calculate the incidence rate of pediatric shoulder dislocations in the United States. Secondary goals were to characterize the demographic information of children with shoulder dislocations as well as trends in management. The US Collaborative Network in TriNetX, a network of clinical data repositories containing patient data from over 100,000,000 unique individuals within the United States, was queried for patients younger than 18 years old diagnosed with shoulder dislocation from 2014 to 2024 using ICD codes. The demographic details were then extracted from the data set, and treatment approaches were determined by CPT coding. Over the past 10 years, there were 16,460 pediatric and adolescent patients diagnosed with a first-time shoulder dislocation in either an ED or ambulatory clinic. The overall incidence rate was 60.31 per 100,000 patients, while the incidence rate was 116.61 per 100,000 patients presenting in the ED and 33.95 per 100,000 patients presenting in ambulatory clinics that were under the age of 18 years. Most patients were male (73%), White (59%), and came from the southeastern region of the United States (36%). The most common treatment was a closed reduction (25%), followed by arthroscopic surgery (17%). The number of annual shoulder dislocations has increased over the past decade without an increase in the number of patients undergoing surgical treatment. There remains a high incidence rate of shoulder dislocations in the pediatric population of the United States. Despite evidence that early surgical treatment of shoulder dislocations offers improved outcomes, nonoperative treatment continues to be the most common modality without any increase in the percentage of patients undergoing surgical treatment. Level IV-descriptive epidemiological analysis.

11 Is emergency department transfer always required following anaphylaxis and epinephrine use?

Abstract Background Patients known for anaphylaxis are advised to always carry 2 epinephrine auto-injectors (EAI) with them. With epinephrine being the first-line treatment for anaphylaxis, current guidelines recommend prompt EAI administration, followed by observation in the emergency department (ED) for 4 hours. Data supporting transfer to the ED in all cases after epinephrine are sparse. Recent North American allergy guidelines no longer suggest that ED presentation after EAI use is required for all cases of anaphylaxis. Objectives We aimed to describe the need for additional ED treatment in children known for food-triggered anaphylaxis who received at least 1 EAI pre-hospital. Design/Methods Data on children under 18 years with food-induced anaphylaxis who received at least one dose of pre-hospital epinephrine was collected from the Cross-Canada Anaphylaxis REgistry (C-CARE) from seven hospitals. A standardized questionnaire obtained information on symptoms, allergens, comorbidities, and pre-hospital and in-hospital management. Multivariable logistic regression was performed to identify factors associated with ED management, among children who received 1, 2 or 3 or more doses of epinephrine pre-hospital. Results From 2011 to 2023, 1054 children with known food-triggered anaphylaxis and who used one or more EAIs pre-hospital were enrolled in C-CARE. The mean age at reaction was 8.2 (standard deviation [SD] 5.3) years, 648 (60.8%) were male and 82 (7.8%) of reactions were severe (defined as loss of bowel control, cyanosis, respiratory arrest, hypotension and/or circulatory collapse, dysrhythmia, severe bradycardia and/or cardiac arrest, confusion, and loss of consciousness). Primary triggers included peanuts (n=280; 26.6%) followed by tree nuts (n=173; 16.4%). 193 patients (18.3%) had known asthma and 201 received additional dose(s) of epinephrine in the ED, the majority of whom (177, 88.1%) received one dose. Only 2.9% of patients required admission. Among all patients, reactions to egg were less likely to require additional epinephrine (aOR 0.90; 95% CI 0.83, 0.99), and more likely with severe reactions (aOR 1.24; 95% CI 1.14-1.35). Among patients who received only one EAI pre-hospital, severe reactions (adjusted odds ratio [aOR] 1.19; 95% confidence interval [CI] 1.08-1.31) and reactions to tree nuts (aOR 1.12; 95% CI 1.04-1.20) were associated with increased odds of an additional dose of epinephrine in hospital. Conclusion One-fifth of anaphylaxis cases that used EAI require an additional dose of epinephrine in ED. Children with severe reactions and reactions to tree nuts are more likely to require additional doses; these cases should be considered for ED transfer and treatment following pre-hospital EAI use.

Youth suicidality risk relative to ambient temperature and heatwaves across climate zones: A time series analysis of emergency department presentations in New South Wales, Australia.

Youth suicidality prevalence continues to rise alongside hot weather severity. Links between these two variables are underexplored. We examined associations between daily temperature and emergency department suicidality presentations by young people. We assessed these associations for five regions covering New South Wales as determined by 'climate zone' and analysed for heatwave effects as well as based on demographic subgroups. Daily emergency department presentations for suicidality by people aged 12-24 years across New South Wales, Australia, during warmer months (November to March) from 2012 to 2019 were examined in relation to daily mean temperature and heatwaves (⩾3 consecutive days ⩾ 95th percentile of long-term daily mean temperature) and by climate zone, using a generalised additive model with negative binomial distribution. Risks for age- and sex-based subgroups were also calculated. New South Wales youth suicidality presentation rates were significantly higher on hotter days. For every 1°C rise above average daily mean temperature, youth suicidality presentations to New South Wales emergency departments increased by 1.3%. Heatwaves did not increase presentation rates beyond single-day daily mean temperature effects. These findings were predominantly replicated across climate zones and demographic subgroups, though the association between suicidality and ambient temperature was weaker in coastal regions including Eastern Sydney. There is a positive linear association between ambient temperature and youth suicidality presentations to emergency departments. Risks are increased on single hot days, not only during heatwaves. Public health, broader societal approaches to heat and health system planning should consider impacts on youth suicidality of predicted increases in hot weather severity and frequency.

Cannabis-Related Disorders Are Associated with Increased Early Postoperative Opioid Prescriptions and Delayed Emergency Department Visits Following Open Carpal Tunnel Release.

The effect of cannabis on pain management following open carpal tunnel release (CTR) surgery is unknown. The purpose of this study is to compare outcomes for patients with cannabis-related disorder (CRD) undergoing open CTR to a propensity-matched cohort of patients without CRD (no cannabis-related disorder [NCRD]). The TriNetX Research Network was queried to identify patients undergoing primary open CTR between January 2010 and December 2022. Patients with CRD were propensity matched to a NCRD cohort in a 1:1 ratio based on 7 characteristics. Rates of postoperative opioid prescriptions, emergency department (ED) services, and outpatient appointments were reported at 0-2, 2-6, and 6-12 weeks postoperatively. A total of 925 CRD patients were propensity matched to 925 NCRD patients undergoing open CTR. Within 0-2 weeks postoperatively, CRD patients received significantly greater rates of opioid prescriptions compared to NCRD patients (30.9% and 25.6%, P = .011). No cannabis-related disorder (NCRD) patients presented for outpatient follow-up at significantly higher rates than CRD patients within 6 weeks postoperatively. CRD patients presented to the ED at significantly higher rates between 6 and 12 weeks postoperatively (11.0% vs. 8.0%, respectively, P = .027). Cannabis-related disorder (CRD) is associated with lower rates of outpatient follow-up but higher rates of postoperative opioid prescriptions and ED presentations following open CTR compared to a propensity-matched cohort of NCRD patients. Cohort Study; Level III.

Multidisciplinary protocol to reduce surgical readmissions in Australia: American College of Surgeons National Surgical Quality Improvement Program.

Unplanned readmissions in general surgery are an important quality indicator of patient care and are associated with increased costs to healthcare services. This study aims to implement a multidisciplinary protocol in a single institution in a tertiary referral hospital to monitor and reduce unplanned readmission rates. A prospective cohort study using an institution-based protocol was conducted over an 18-month period including patients undergoing a general surgical procedure. The protocol included: (i) implementation of a surgical readmissions nurse-patient liaison; (ii) access to a surgical walk-in clinic; and (iii) early post-discharge phone contact. Data included demographic details, index procedure, hospital length of stay (LOS), and whether contact between patient/nurse occurred upon discharge. The primary outcome was the cause and rate of 30-day readmissions. Secondary outcomes were mortality, use of surgical clinic, emergency department presentations, and complications. After protocol implementation, 874 patients underwent a general surgical procedure, with 354 (49%) being male and an overall median age of 53.0 years (interquartile range: 36.0-67.0). The overall readmission rate was 5.6% (n = 49), with a median LOS after readmission of 4 days. Compared with historical pre-protocol ACS-NSQIP data, this reflects a 30% reduction compared to that of readmission rate of 7.9%, P = 0.03. The multidisciplinary protocol was efficacious in significantly reducing unplanned readmissions. Continued audits and monitoring of factors associated with readmissions are required to help design targeted projects that may lead to improved outcomes, lower costs, increased patient satisfaction, and better efficiency within our healthcare system.

Mechanisms and Trends in Women's Lacrosse Head and Musculoskeletal Injuries: A 15-Year Review of National Injury Data.

Head injury rates in lacrosse may be higher among women compared with men. Understanding these trends can guide appropriate injury prevention for female athletes. Injuries most commonly involve the head, with no significant decline over the study period; contact with other players would be the most common injury mechanism. Descriptive epidemiological. Level 3. The National Electronic Injury Surveillance System (NEISS) was queried (January 1, 2008 to December 31, 2022) for women's lacrosse injuries presenting to United States (US) emergency departments (EDs). Patient demographics, injury diagnosis, body part injured, disposition, and clinical narrative were extracted. The provided narrative identified the mechanism of injury. Linear regression analysis assessed trends over time. An estimated 57,635 women's lacrosse injuries occurred during the study period extrapolated from 1899 evaluated NEISS cases. The mean age was 15.81 ± 5.35 years, with 68.3% of injuries sustained by high school (14- to 18-year-old) players. Over one-third of all injuries were to the head (national estimate [NE], 19,358; 33.6%), followed by the ankle (NE, 10,475; 18.2%), then the knee (NE, 6969; 12.1%). Strain/sprains were most common (NE, 19,402; 33.7%) followed by closed head injury (CHI)/sports-related concussion (SRC) (NE, 11,794; 20.5%) and contusion/abrasion (NE, 10,605; 18.4%). ED presentations of CHIs/SRCs and fractures remained elevated with no significant decline over the study period (P > 0.05), despite a significant decrease in strains/sprains and contusions/abrasions (P < 0.01 and P = 0.01, respectively). The most common injury mechanism was collision/contact with another player (NE, 10,664; 18.5%). An estimated one-third of women's lacrosse players in the study sample had a head injury. CHIs and SRCs accounted for 20.5% of all injuries. Given the high proportion of contact-related head injuries, headgear mandates and improved player safety protocols may be warranted.

Prediction of 90-day mortality risk after unplanned emergency department visits of advanced stage cancer patients

PurposeCancer represents the leading cause of mortality in high-income countries. In the last years, the rate of emergency department (ED) visits by cancer patients has increased 5.5-fold. These ED visits impose a significant economic burden and may indicate the progression of the oncologic disease. The goal of this retrospective study was to identify patient-derived risk factors, especially focusing on serum albumin and body mass index (BMI) for 90-day mortality following unplanned ED visits by cancer patients.MethodsA retrospective chart review of all patients with an ICD-10 diagnosis for cancer undergoing palliative treatment presenting at the ED between 2016 and 2018 at the General Hospital of Vienna was performed. Laboratory values, emergency severity index (ESI), and BMI were collected at the ED presentation. 90-day mortality (90MM) was calculated from the ED presentation.ResultsA total of 448 cancer patients were included. Lung cancer (19.2%) and pancreaticobiliary cancer (15.6%) were the most frequent diagnoses. The main reasons for ED visits were pain (20.5%) and fever (17.4%). Sixty-nine percent of patients had to be admitted and 17.5% of patients died during hospitalization. 90MM was highest for patients with low albumin (< 35 g/L vs. > 35 g/L: 60.4% vs. 31.4%; p < .0001). When incorporating albumin levels and BMI, patients with both values below the cutoff had the highest risk for death (HR 4.01, 95% CI 2.30–7.02).ConclusionCancer patients face a high risk for hospitalization when presenting at the ED. The 90MM rate is highest in patients with low BMI and albumin levels. This highlights an especially vulnerable cohort of cancer patients for whom supportive care and palliative care have to be optimized.

Long-term Outcomes Following Non-operative Management of Acute Appendicitis: A Population-based Analysis.

To describe long-term re-presentations and interventions following non-operative management (NOM) of acute appendicitis (AA). Trial data suggest NOM of AA carries a substantial risk of subsequent appendectomy, although NOM is increasingly offered to patients. Population-based data is required to understand the real-world long-term course of patients undergoing NOM of AA. This population-based cohort study included all adult patients in Ontario, Canada who presented to any emergency department (ED) with AA between 2004-2019. Patients who did not undergo a procedure on index ED presentation or hospital admission were defined as NOM and followed for five years. The cumulative incidence of composite re-presentation or intervention (ED re-presentation, re-admission, emergency, or scheduled appendicitis procedure) was calculated accounting for competing risk of death. Of 156,362 patients identified with AA, 13,200 underwent NOM. The cumulative incidence of composite re-presentation or intervention was 33% at 1-year (95%CI 32-33%) and 36% at 5-years (95%CI 36-37%). At 5-years, the incidence of appendicitis-specific ED re-presentation or hospital re-admission was 16% (95%CI 15-16%), the incidence of an emergency procedure for AA was 12% (95%CI 12-13%), and the incidence of scheduled surgery was 21% (95%CI 20-21%). In a subgroup of patients with uncomplicated AA, composite re-presentation or intervention was 28% at 1-year (95%CI 27-29%) and 32% at 5-years (95%CI 32-33%). Real-world estimates of emergency re-presentation with or without urgent surgery following NOM of AA were lower than previously described. Scheduled appendectomy made up an important proportion of long-term interventions following NOM.