Rates Of Emergency Department Research Articles

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018.

In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care. Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery. A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management. This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges. Level III-retrospective cohort.

Acute Care Use by Breast Cancer Patients on Adjuvant Chemotherapy in Alberta: Demonstrating the Importance of Measurement to Improving Quality.

Breast cancer patients receiving adjuvant chemotherapy are at increased risk of acute care use. The incidence of emergency department (ED) visits and hospitalizations (H) have been characterized in other provinces but never in Alberta. We conducted a retrospective population-based cohort study using administrative data of women with stage I-III breast cancer receiving adjuvant chemotherapy. Rates of ED and H use in the 180 days following chemotherapy initiation were determined, and logistic regression was performed to identify risk factors. We found that 47% of women receiving adjuvant chemotherapy experienced ED or H, which compared favourably to other provinces. However, Alberta had the highest rate of febrile neutropenia-related ED visits, and among the highest chemotherapy-related ED visits. The incidence of acute care use increased over time, and there were significant institutional differences despite operating under a single provincial healthcare system. Our study demonstrates the need for systematic measurement and the importance of quality improvement programs to address this gap.

Use of a Sterile Collection Process to Reduce Contaminated Peripheral Blood Cultures.

Contaminated blood cultures pose a significant burden by subjecting children to unnecessary testing, procedures, and antibiotics and increasing health care costs. The aim of our quality improvement (QI) initiative was to decrease the percentage of contaminated peripheral blood cultures in our pediatric emergency department (ED) from an average of 6.7% to <3% over a 16-month period. The QI initiative was implemented in the pediatric ED of a tertiary care children's hospital. Interventions included change of the peripheral blood culture collection from a clean to a sterile process, nursing education, and individualized feedback. The primary outcome measure was the percentage of contaminated peripheral blood cultures. The process measure was the percentage of nurses who completed 75% to 100% of the steps of the sterile collection process, as measured by self-reporting in audit cards. The balancing measures were time from antibiotic ordering to time of administration and ED length of stay. We decreased the percentage of contaminated peripheral blood cultures threefold from a baseline (June 2, 2018, to December 31, 2018) of 6.7% to 2.1% during the intervention period (January 1, 2019, to April 30, 2020). Ninety-eight percent of nurses who completed audit cards reported performing 75% to 100% of the steps of the new sterile process. There was no significant difference in the average time from antibiotic ordering to antibiotic administration or ED length of stay between the baseline and intervention periods. Use of a sterile blood culture collection process, in addition to nursing education and individualized feedback, is an effective method to decrease peripheral blood culture contamination rates in a pediatric ED.

Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations.

Extensive literature supports using dexamethasone (DEX) in children presenting to the emergency department (ED) with mild-to-moderate asthma exacerbations; however, only limited studies have assessed this in hospitalized children. In this study, we evaluate the outcomes of DEX versus prednisone/prednisolone (PRED) use in children hospitalized for mild-to-moderate asthma exacerbations. This multisite retrospective cohort study included children between 3 and 21 years of age hospitalized to a tertiary care children's hospital system between January 1, 2013, and December 31, 2017, with a primary discharge diagnosis of acute asthma exacerbation or status asthmaticus. Primary study outcome was mean hospital length of stay (LOS). Secondary outcomes included PICU transfers during initial hospitalization and ED revisits and hospital readmissions within 10 days after discharge. Generalized linear models were used to model logged LOS as a function of steroid and demographic and clinical covariates. The analysis was stratified by initial steroid timing. Of the 1410 children included, 981 received only DEX and 429 received only PRED. For children who started oral steroids after hospital arrival, DEX cohort had a significantly shorter adjusted mean hospital LOS (DEX 24.43 hours versus PRED 29.38 hours; P = .03). For children who started oral steroids before hospital arrival, LOS did not significantly differ (DEX 26.72 hours versus PRED 25.20 hours; P = .45). Rates of PICU transfers, ED revisits, and hospital readmissions were uncommon events. Children hospitalized with mild-to-moderate asthma exacerbations have significantly shorter hospital LOS when starting DEX rather than PRED on admission.

Activity Monitoring for Early Detection and Management of Toxicity in Patients Undergoing Chemoradiation for Gastrointestinal Malignancy

<h3>Purpose/Objective(s)</h3> Higher levels of physical activity assessed by step count have been associated with lower risk of hospitalization during cancer treatment. We hypothesize that it is feasible to use activity data to identify patients undergoing concurrent chemoradiation for gastrointestinal (GI) malignancy who are at high risk for emergency department (ED) visits and hospitalizations, and to successfully trigger and execute triage visits for symptom management. <h3>Materials/Methods</h3> This prospective study randomized patients to activity monitoring versus observation. Each group was provided an activity monitor. If a patient in the intervention arm had 20% decreased activity or 20% increase in heart rate from their baseline, a triage visit was triggered to evaluate and treat symptoms. In the observation group, activity data was recorded but no triage visit was triggered. Baseline step count and heart rate were established during a one-week period between radiation simulation and treatment start. The primary endpoint was to demonstrate an increased rate of triage visits in the activity monitoring group compared to observation. Secondary outcomes included rates of ED visits and hospitalizations. Crude and adjusted odds ratios (OR) were computed using logistic regression modeling. <h3>Results</h3> A total of 40 patients were enrolled on the study: 22 in the intervention group and 18 in the observation group. Primary disease sites included anus (n = 4), gastric/esophagus (n = 14), hepatobiliary (n = 4), pancreas (n = 7), and rectum (n = 11). Median age was 60 years in the intervention arm and 62.5 years in the observation arm (<i>P</i> = 0.69). The median radiation dose and fractionation were similar among the two groups. Average baseline daily step counts were similar in the two groups (5,103 in intervention group vs. 5,668 in observation group, <i>P</i> = 0.43). Average daily step counts decreased from week 1 to week 5 in both groups (-960 steps in observation group and -1,164 steps in the intervention group). There was an increased rate of triage visits in the intervention arm compared to the observation arm (86.4% v 38.9%, OR 9.95, 95% CI 2.12-46.56, <i>P</i> = 0.015). Rates of ED visits and hospitalizations were numerically lower in the intervention group compared to the observation group (9.1% vs 22.2%, <i>P</i> = 0.31; 4.5% vs 16.7%, <i>P</i> = 0.31, respectively). Patients with anal (-1456 steps) cancer showed the largest decrease in mean daily step count over the treatment course. Medical intervention was more common in the intervention group compared to observation (<i>P</i> < 0.001). <h3>Conclusion</h3> This study supports the feasibility of actively monitoring patient's daily step and heart rate data to successfully trigger triage visits for patients at high risk for toxicity. Further studies are ongoing and may support the use of automated activity monitoring to decrease the rates of ED visits and hospitalizations.

Analysis of Emergency Department Visits and Unplanned Readmission After Bariatric Surgery: An Experience From a Tertiary Referral Center.

Bariatric surgery is the most effective treatment of morbid obesity. As the number of bariatric procedures performed has increased, visits to the emergency department (ED) and readmissions have subsequently increased. The present study aimed to assess the rates and indications for of ED visits and readmission after bariatric surgery and to identify the predictors of hospital readmission. This was a retrospective cohort study on patients who underwent bariatric surgery from January 2018 to April 2020. The percentage of ED visits and unplanned readmission was estimated and the indications and management of each were analyzed. The association of age, sex, body mass index, and type of procedure with readmission was assessed. Of 582 patients who underwent bariatric surgery in the study period, 204 (35%) required ED visits, and 42 (7.2%) required readmission. The mean age of patients was 33 years, and the mean body mass index was 43 kg/m2. The most common indication for ED visits was abdominal pain (41.2%). In all, 64.8% of ED visits and 43% of readmissions were unrelated to bariatric surgery complications. A total of 94.1% of patients who required ED visits and 71.4% of readmitted patients were managed conservatively. The most common procedure followed by readmission was laparoscopic sleeve gastrectomy (50%) then one-anastomosis gastric bypass (21.4%). Age, sex, body mass index, and procedure type were not significantly associated with higher readmission. The rates of ED visits and readmission in our cohort were 35% and 7.2%, respectively. Most cases of ED visits were not related to adverse effects of bariatric surgery and the majority of which were managed conservatively.

US Emergency Department Visits Attributed to Medication Harms, 2017-2019

Assessing the scope of acute medication harms to patients should include both therapeutic and nontherapeutic medication use. To describe the characteristics of emergency department (ED) visits for acute harms from both therapeutic and nontherapeutic medication use in the US. Active, nationally representative, public health surveillance based on patient visits to 60 EDs in the US participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project from 2017 through 2019. Medications implicated in ED visits, with visits attributed to medication harms (adverse events) based on the clinicians' diagnoses and supporting data documented in the medical record. Nationally weighted estimates of ED visits and subsequent hospitalizations for medication harms. Based on 96 925 cases (mean patient age, 49 years; 55% female), there were an estimated 6.1 (95% CI, 4.8-7.5) ED visits for medication harms per 1000 population annually and 38.6% (95% CI, 35.2%-41.9%) resulted in hospitalization. Population rates of ED visits for medication harms were higher for patients aged 65 years or older than for those younger than 65 years (12.1 vs 5.0 [95% CI, 7.4-16.8 vs 4.1-5.8] per 1000 population). Overall, an estimated 69.1% (95% CI, 63.6%-74.7%) of ED visits for medication harms involved therapeutic medication use, but among patients younger than 45 years, an estimated 52.5% (95% CI, 48.1%-56.8%) of visits for medication harms involved nontherapeutic use. The proportions of ED visits for medication harms involving therapeutic use were lowest for barbiturates (6.3%), benzodiazepines (11.1%), nonopioid analgesics (15.7%), and antihistamines (21.8%). By age group, the most frequent medication types and intents of use associated with ED visits for medication harms were therapeutic use of anticoagulants (4.5 [95% CI, 2.3-6.7] per 1000 population) and diabetes agents (1.8 [95% CI, 1.3-2.3] per 1000 population) for patients aged 65 years and older; therapeutic use of diabetes agents (0.8 [95% CI, 0.5-1.0] per 1000 population) for patients aged 45 to 64 years; nontherapeutic use of benzodiazepines (1.0 [95% CI, 0.7-1.3] per 1000 population) for patients aged 25 to 44 years; and unsupervised medication exposures (2.2 [95% CI, 1.8-2.7] per 1000 population) and therapeutic use of antibiotics (1.4 [95% CI, 1.0-1.8] per 1000 population) for children younger than 5 years. According to data from 60 nationally representative US emergency departments, visits attributed to medication harms in 2017-2019 were frequent, with variation in products and intent of use by age.

Unintended but Hardly Unexpected Consequences of Cannabis Legalization

Unintended but Hardly Unexpected Consequences of Cannabis Legalization

Changes in Primary Care Telehealth Use and Impact on Acute Care Visits for Ambulatory Care‐Sensitive Conditions during COVID‐19

Research ObjectiveThe COVID‐19 pandemic forced a dramatic shift from in‐person care to telehealth, with an overall decrease in outpatient utilization. These changes particularly stressed outpatient care delivery and may have resulted in decreased availability and access to primary care for patients, potentially increasing otherwise avoidable emergency department (ED) visits and hospitalizations. One commonly used indicator of primary care access and quality is acute care visits for ambulatory care‐sensitive conditions (ACSCs), such as for pneumonia, uncontrolled diabetes, or congestive heart failure exacerbations. Our study examined differences in telehealth adoption across practices and evaluated the association between telehealth adoption and ACSC visits.TABLE 1Differences‐in‐differences model of practice telemedicine conversion rate on acute care visits for acute and chronic ACSCsAcute ACSC aOR (95% CI)Chronic ACSC aOR (95% CI)Telemedicine tertile (mean telemedicine conversion rate)Low (9%)refrefMedium (30%)0.98 (0.91–1.07)0.98 (0.76–1.26)High (66%)1.07 (0.98–1.17)1.14 (0.86–1.50)Study DesignWe conducted a retrospective study of claims data from a large commercial insurer in Michigan. We first profiled telehealth adoption by primary care practices during March–July 2020. We defined a practice's “telehealth conversion rate” as the proportion of visits conducted via telehealth during this period compared to the total number of visits during the same period in 2019. Then, to enable comparison between groups at a time when both outpatient and acute care visits were in flux, we used a differences‐in‐differences (DID) model to determine whether varying levels of primary care telehealth conversion were associated with differences in acute care visits (ED visits and hospitalizations) for ACSCs from June–September 2020. We examined visit rates for acute and chronic ACSCs separately, controlling for practice size, in‐person visit volume, and zip code‐level attributes as well as patient characteristics (age, gender, comorbidities). We performed sensitivity analyses using varying definitions of telemedicine conversion rates and multiple model specifications.Population StudiedSix million Blue Cross Blue Shield of Michigan beneficiaries across 3780 primary care practices from January 2019 to September 2020.Principal FindingsAverage primary care practice telehealth conversion rate was 25% (median 10%), and 29% of practices had no telehealth claims identified. Practices that did not adopt telehealth tended to be smaller and were more likely to be in rural areas. We found no significant differences in the rate of ED visits and hospitalizations for ACSCs by practice‐level telemedicine conversion tertile after adjusting for practice case‐mix, as shown in Table 1. Sensitivity analyses showed similar results.ConclusionsBeneficiaries within a large commercial payer experienced rapid shifts from in‐person to telehealth for their primary care, though telehealth adoption was not evenly distributed, with smaller and more rural practices being less likely to adopt telemedicine. These changes did not seem to obviously help or harm patients as ED visits and hospitalizations for ACSCs were similar across groups.Implications for Policy or PracticeWidespread substitution of telehealth for in‐person care had little impact on cost of care with respect to avoidable ED visits and hospitalizations in the near‐term. Additional research should continue to monitor this trend as health care utilization stabilizes beyond the pandemic.Primary Funding SourceUniversity of Michigan Institute for Health Policy and Innovation.

MP17-15 FREQUENCY AND TIMING OF EMERGENCY DEPARTMENT VISITS AND HOSPITAL ADMISSIONS FOLLOWING COMMON STONE PROCEDURES

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures I (MP17)1 Sep 2021MP17-15 FREQUENCY AND TIMING OF EMERGENCY DEPARTMENT VISITS AND HOSPITAL ADMISSIONS FOLLOWING COMMON STONE PROCEDURES Rohail Rashid Kazi, Molly Jung, Yan Xiong, Timothy Kelly, and Andrew Harris Rohail Rashid KaziRohail Rashid Kazi More articles by this author , Molly JungMolly Jung More articles by this author , Yan XiongYan Xiong More articles by this author , Timothy KellyTimothy Kelly More articles by this author , and Andrew HarrisAndrew Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002002.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Emergency department (ED) visits and hospital admissions (HA) following urologic procedures are a concern for payors, providers, and patients. We seek to quantify ED visits and HA after urologic stone procedures. METHODS: A retrospective analysis was conducted using claims data from IBM MarketScan Commercial and Medicare Supplement databases. Adults with urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), or shockwave lithotripsy (SWL) and had ureteral stent codes during the index procedure between 2012 and 2017 were analyzed. All cause vs GU-specific ED visits and HA were evaluated during 30, 60, 90, and 120-day periods. RESULTS: 88,047 patients with mean age of 52.6 years and 44% female gender were identified that met inclusion criteria. Of these patients, 8,924 (10%) had their index procedure as an inpatient and 79,123 (90%) as an outpatient. For inpatients, rate of all cause vs GU-specific ED visits was 10% vs 9% at 30 days, 14% vs 12% at 60 days, 16% vs 14% at 90 days, and 19% vs 15% at 120 days. For outpatients, rate of all cause vs GU-specific ED visits was 9% vs 8% at 30 days, 11% vs 10% at 60 days, 13% vs 11% at 90 days, and 15% vs 12% at 120 days. A similar trend was found when examining rate of all-cause vs GU-specific HA. Younger patients (18-44 years old) tended to have higher rates of ED visits than older patients (>65 years old) following inpatient index stone procedure (13.4% vs 9.6% at 30 days, p ≤0.01). Patients with CCI ≥2 had higher rates of unplanned ED visits following stone procedures compared with those with CCI = 0 (11.3% vs 9.7%, p <0.01). CONCLUSIONS: Nearly one-fifth of patients have an unplanned hospital visit up to 120 days after having stone procedure, regardless of site of treatment. The majority of these visits involve GU-related diagnoses. Younger patients and patients with higher number of comorbidities have unplanned hospital visits in greater proportion than older patients and patients with fewer comorbidities. Further studies need to determine causation of these unplanned visits in order to guide appropriate intervention. Source of Funding: IBM Marketscan Database information provided by BD © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e314-e314 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rohail Rashid Kazi More articles by this author Molly Jung More articles by this author Yan Xiong More articles by this author Timothy Kelly More articles by this author Andrew Harris More articles by this author Expand All Advertisement Loading ...

Second and later-line erlotinib use in non-small cell lung cancer: real world outcomes and practice patterns overtime in Canada.

BackgroundIn Canada, epidermal growth factor receptor (EGFR) inhibitor therapies in advanced non-small cell lung cancer (NSCLC) were initially approved regardless of EGFR status. The purpose of this study is to characterise the use of second or later-line erlotinib therapy in Ontario, Canada from 2007–2016, as well as evaluate the impact of erlotinib therapy on survival and emergency department (ED) visits in a real-world population.MethodsThis is a retrospective cohort study derived at ICES (formerly known as the Institute for Clinical and Evaluative Sciences) of advanced NSCLC patients diagnosed from 2007–2016 in Ontario, Canada, over the age of 65, who received at least one dose of first-line chemotherapy. The exposure of interest was receipt of second or later-line erlotinib. The primary outcome was the hazard ratio for mortality evaluated using a Cox proportional hazards model, and the secondary outcome, ED visits, was evaluated using a Poisson model.ResultsFirst-line chemotherapy was administered in 30.4% of stage IV NSCLC patients. Of these patients, 19.7% received second or later-line erlotinib. The proportion of patients prescribed second or later-line erlotinib decreased over the course of the study (P<0.0001). Unadjusted median overall survival in the entire cohort was 325 days (95% CI: 314–337 days), 513 days (95% CI: 485–539 days) in the erlotinib cohort, and 282 days (95% CI: 270–291 days) in the non-erlotinib cohort. Despite this, the adjusted hazard ratio for death was 1.89 (95% CI: 1.73–2.07, P<0.0001) for patients on erlotinib. Patients receiving erlotinib also had a marginally higher relative rates of ED visits with an adjusted relative risk of 1.10 (95% CI: 1.02–1.19, P=0.013).ConclusionsThis study highlights the importance of using EGFR targeted treatments in NSCLC patients with a predictive biomarker, and suggests that treatment with erlotinib therapy is unlikely to benefit unselected patients with advanced NSCLC.

The impact of the national stay-at-home order on emergency department visits for suspected opioid overdose during the first wave of the COVID-19 pandemic

BackgroundAlthough national syndromic surveillance data reported declines in emergency department (ED) visits after the declaration of the national stay-at-home order for COVID-19, little is known whether these declines were observed for suspected opioid overdose. MethodsThis interrupted time series study used syndromic surveillance data from four states participating in the HEALing Communities Study: Kentucky, Massachusetts, New York, and Ohio. All ED encounters for suspected opioid overdose (n = 48,301) occurring during the first 31 weeks of 2020 were included. We examined the impact of the national public health emergency for COVID-19 (declared on March 14, 2020) on trends in ED encounters for suspected opioid overdose. ResultsThree of four states (Massachusetts, New York and Ohio) experienced a statistically significant immediate decline in the rate of ED encounters for suspected opioid overdose (per 100,000) after the nationwide public health emergency declaration (MA: -0.99; 95 % CI: -1.75, -0.24; NY: -0.10; 95 % CI, -0.20, 0.0; OH: -0.33, 95 % CI: -0.58, -0.07). After this date, Ohio and Kentucky experienced a sustained rate of increase for a 13-week period. New York experienced a decrease in the rate of ED encounters for a 10-week period, after which the rate began to increase. In Massachusetts after a significant immediate decline in the rate of ED encounters, there was no significant difference in the rate of change for a 6-week period, followed by an immediate increase in the ED rate to higher than pre-COVID levels. ConclusionsThe heterogeneity in the trends in ED encounters between the four sites show that the national stay-at-home order had a differential impact on opioid overdose ED presentation in each state.

The association between prescription opioid dispensing and opioid-related morbidity and mortality in Ontario, Canada: an ecological study of public health units

ObjectiveOverdose and death rates from opioids continue to rise. However, the relative contribution of prescription opioids to the ongoing crisis is unclear. The purpose of this study was to assess the association between prescription opioid dispensing and opioid-related morbidity and mortality. MethodsRegional-level data for this ecological study were extracted from publicly available databases for the years 2013–2018 in Ontario, Canada. The primary exposure variable was opioids dispensed, in milligram morphine equivalents (MME), per capita by public health unit (PHU) in a given year. The primary outcome was the rate of opioid-related emergency department (ED) visits per 100,000 by PHU. Generalized estimating equation (GEE) analytic models were developed to account for clustering by PHU over time while adjusting for demographic and population health characteristics at the regional level. ResultsHigher per capita MME of opioids dispensed was associated with lower rates of opioid-related ED visits per 100,000 (β=-0.091, 95 % CI: -0.110 to -0.077, p < 0.001), as well as with lower rates of opioid-related deaths per 100,000 (β=-0.012, 95 % CI: -0.014 to -0.007, p < 0.001). In subgroup analyses based on time periods (2016–2018 vs. 2013–2015), this negative association was seen only for the period 2016–2018. InterpretationHigher per capita regional opioid prescribing was not positively associated with an increased rate of opioid-related emergency room visits or opioid-related deaths. Further studies with patient-level data are needed to better understand our findings.

Association of limited English proficiency and increased pediatric emergency department revisits.

Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits. This was a retrospective, cross-sectional study of patients 0 to 21years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted. There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference= 0.97, 95% confidence interval [CI]= 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR]= 1.15, 95% CI= 1.01 to 1.30) and in hospitalization (OR= 1.28, 95% CI= 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results. These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Ambient Heat is associated with higher risk of emergency department visits among US children with health insurance

BACKGROUND AND AIM: Extreme heat is a recognized threat to public health and the effect of high outdoor temperatures on adults is well characterized. Children are thought to be particularly susceptible to heat, but the evidence remains scarce. Accordingly, we aimed to estimate the association between warm-season temperatures and cause-specific emergency department (ED) visits in US children. METHODS: We leveraged national de-identified ED visits between May and September of 2016-2020 among children 18 years of age with commercial health insurance using the OptumLabs® Data Warehouse. We estimated daily population-weighted county average maximum temperature using a validated gridded climate dataset. We used a time-stratified case-crossover study design with a distributed lag nonlinear model to estimate the association between daily maximum temperature and relative rate of ED visits for each of 22 major disease categories, adjusting for relative humidity and federal holidays. RESULTS:We identified a total of ~1.3 million ED visits for any cause among children with commercial health insurance living in 2,987 US counties. A 10 °C increase in daily maximum temperature was associated with a 25% (95% CI: 18%, 32%) higher rate of ED visits for heat-related illness, a 9% (5%, 13%) higher rate of ED visits for otitis media and externa, and a 9% (3%, 15%) higher rate of ED visits for skin and soft tissue infections. Temperature was not associated with all-cause ED visits and potentially protective associations were observed for multiple outcomes, including respiratory system diseases and mental health. CONCLUSIONS:In this large, national study of children with health insurance, we found that heat is associated with higher rates of emergency department visits for a range of conditions. These results suggest that children are susceptible to heat and may inform public health and clinical efforts to protect this vulnerable population. KEYWORDS: extreme heat, children's health, climate, emergency department

Air pollution and emergency department visits for urticaria

BACKGROUND AND AIM: The objective of this work was to investigate correlations between air pollution and emergency department (ED) visits for urticaria in Toronto, Canada. METHODS: The National Ambulatory Care Reporting System database was used to draw the diagnosed ED visits. The L50 section of the International Classification of Disease 10th Revision was used to extract ED visits whose primary causes of visit was urticaria-related conditions. Statistical models (Poisson regression) using daily counts of ED visits were created for urticaria, ambient air pollution concentrations, and weather factors. We considered two air quality health indexes and six ambient air pollutants for exposure: fine particulate matter PM2.5, O3, CO, NO2, SO2, and maximum 8-hour average ozone. RESULTS:A total of 176 statistically significant (P-Value 0.05) positive correlations were identified over the 14 day lag period. For ozone,74 positive correlations were observed with the following relative risks (RR) for one interquartile range (IQR=12.8 ppb) increase: RR=1.361 (95% confidence interval: 1.302, 1.404), 1.359 (1.299, 1.401), 1.351 (1.281, 1.404) in the warm season (April-September), lag 0, and RR=1.019 (1.013, 1.025), 1.023 (1.016, 1.030), 1.014 (1.007, 1.021), lag 1, in the cold period (October-March), for all, females, and males, respectively. 10, 45 and 45 positive correlations were also obtained for sulfur dioxide, fine particulate matter, and daily maximum 8-hour average ozone concentrations, respectively. CONCLUSIONS:The results indicate that urban ambient air pollution could influence the rates of ED visits for urticaria. Ambient ozone was determined as the main environmental factor contributing to these associations. KEYWORDS: Ozone, Traffic-related, Short-term exposure, Allergies

Injury-Related Emergency Department Presentations Among Residential Aged Care Residents in Victoria, Australia.

This study aimed to quantify and describe the characteristics of emergency department (ED) injury presentations and subsequent hospital admissions among residents of residential aged-care facilities (RACFs) in Victoria, Australia between 2008 and 2018. This study comprised a single jurisdiction population-based study of consecutive injury-related ED presentations of RACFs residents using the Victorian Emergency Minimum Dataset (VEMD). The rate of ED injury presentations per 100,000 population decreased by .8% per year over 10years (P = .03); however, the rate per 100,000 RACF bed days increased by .6% per year (P = .05). The proportion of presentations subsequently admitted to hospital increased 4.0% per year (P<.0001). The majority of presentations were due to falls (82.5%), with fracture(s) being the most common injury type (34.0%). The increased rate of ED visits and hospital admissions in RACFs residents highlights the need to design specialized emergency care services and/or provide better direct access to hospital care for this vulnerable population.

Practice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project

Practice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project. Megg Wylie, Amelia Srajer, Kevin Lonergan, Philippa Brain, Eddy Lang Background: Practice variation in the management of spontaneous abortion exists in the Emergency Department (ED). We developed a multisite retrospective study to assess how the management of spontaneous abortion has changed over 2014-2019 across four Calgary EDs, with emphasis on assessing variation and trends between non-operative (medical/expectant) and operative (dilatation and curettage) management. Medical management has been increasingly indicated as effective, yet a knowledge gap exists regarding its use. Knowledge of that proportion and physician-level practice variation will facilitate educational and audit and feedback style initiatives. Results provide justification and supporting data for said initiatives, which may be extrapolated to elsewhere. Implementation: Two medical students are heading the day to day work of this project, with support from a principal investigator with the Department of Emergency Medicine in Calgary. We also have the support of a data manager and the head of pregnancy loss in the region. This study was implemented as a quality improvement project. Therefore, the Conjoint Health Research Ethics Board at the University of Calgary was consulted to ensure the project qualified as a quality improvement and that our privacy protections were appropriate. With approval from the ethics board, we needed the data to analyze and assess. To do so, we utilized Sunrise Clinical Manager (SCM) to retrospectively collect data. Sunrise Clinical Manager, a system utilized in Calgary EDs to track patient and department information, was accessed to collect administrative data. Sustaining this work will involve the continued efforts of the described team, largely in writing up the results and disseminating them via audit and feedback procedures. Evaluation Methods: Using SCM, data were retrospectively collected for patients coded with International Classification of Disease (ICD-10) codes O03.4 (incomplete spontaneous abortion without complication) or O02.1 (missed abortion) who presented to an ED in Calgary (Foothills Medical Centre, Peter Lougheed Centre, South Calgary Hospital, and Rockyview General Hospital) over 2014-2019. We collected patient and environmental factors to allow for the examination of unintended associations. Hemoglobin, HCG level, CTAS code, PIA (time to MD), and U/S result (to confirm diagnosis) were collected. Variables regarding length of stay, procedures received (D&amp;Cs, or other), and returns to care (within 72 hours, and 7 days) were collected. Return to care for future D&amp;C was considered a proxy for failed non-operative management. Demographic and practice data were collected on ED physicians who saw a minimum of 15 patients from our cohort, to gain understanding of trends in practice. Data were analyzed using Chi-square and Mann-Whitney U tests. Results: Within our cohort, 1110 (28.9%) patients received a D&amp;C. The remaining 2735 (71.1%) patients were managed non-operatively. Variation and trends were present between sites, with rates of D&amp;Cs ranging from 15.8% to 33.5% (p &lt;0.001). The rate of D&amp;Cs decreased from 34.2% in 2014 to 22.6% in 2019 across all sites (p &lt;0.001), and 11.6% absolute and 33.9% relative reduction; yet there was minimal variation over time in rates of ED returns and returns resulting in D&amp;Cs. 78.6% of physicians who saw ≥ 15 patients were female, with female physicians responding to 81.8% of our cohort Advice and Lessons Learned:1) Our first suggested lesson is to have a clear plan regarding deadlines and timelines, but toalso have room for flexibility. At some times the work on this project was slowed to alloweffective collaboration with the obstetrics and gyneocology department, or to allow for therefinement of data management. By setting realistic timelines, team members wereencouraged to progress the work in a timely fashion. However, by having flexibility the teamwas able to adapt to roadblocks along the way. 2) A second lesson would be the importance of meaningful collaboration between departments.Though the setting of the project was within Calgary EDs, the topic and content have clearrelevance to obstetics and gynaecology. By consulting with members of the obstetrics andgynaecology department we were able to clarify our objectives and have a betterunderstanding of local contextual factors that influenced our results.

Socioeconomic and Geographic Disparities in Emergency Department Visits due to Alcohol in Ontario: A Retrospective Population-level Study from 2003 to 2017.

While the overall health system burden of alcohol is large and increasing in Canada, little is known about how this burden differs by sociodemographic factors. The objectives of this study were to assess sociodemographic patterns and temporal trends in emergency department (ED) visits due to alcohol to identify emerging and at-risk subgroups. We conducted a retrospective population-level cohort study of all individuals aged 10 to 105 living in Ontario, Canada. We identified ED visits due to alcohol between 2003 and 2017 using defined International Classification of Diseases, 10th edition, codes from a pre-existing indicator. We calculated annual age- and sex-standardized, and age- and sex-specific rates of ED visits and compared overall patterns and changes over time between urban and rural settings and income quintiles. There were 829,662 ED visits due to alcohol over 15 years. Rates of ED visits due to alcohol were greater for individual living in the lowest- compared to the highest-income quintile neighbourhoods, and disparities (rate ratio lowest to highest quintile) increased with age from 1.22 (95% CI, 1.19 to 1.25) in 15- to 18-year-olds to 4.17 (95% CI, 4.07 to 4.28) in 55- to 59-year-olds. Rates of ED visits due to alcohol were significantly greater in rural settings (56.0 per 10,000 individuals, 95% CI, 55.7 to 56.4) compared to urban settings (44.8 per 10,000 individuals, 95% CI, 44.7 to 44.9), particularly for young adults. Increases in rates of visits between 2003 and 2017 were greater in rural versus urban settings (82 vs. 68% increase in age- and sex-standardized rates) and varied across sociodemographic subgroups with the largest annual increases in rates of visits in young (15 to 29) low-income women (6.9%, 95%CI, 6.7 to 7.3) and the smallest increase in older (45 to 59) high-income men (2.7, 95%CI, 2.4 to 3.0). Alcohol harms display unique patterns with the highest burden in rural and lower-income populations. Rural-urban and income-based disparities differ by age and sex and have increased over time, which offers an imperative and opportunity for further interventions by clinicians and policy makers.

Implementation of a Procainamide-Based Cardioversion Strategy for the Management of Recent-Onset Atrial Fibrillation.

Atrial fibrillation/flutter (AF) remains the most common rhythm disturbance in adult patients presenting to emergency departments (EDs). Although pharmacologic cardioversion has been established as safe and effective in recent-onset AF, its use in U.S. EDs is uncommon. The purpose of this study was to assess the safety and efficacy of intravenous (IV) procainamide for pharmacologic cardioversion in patients presenting to the ED with AF of <48-hr duration. Patients presenting to the ED with recent-onset AF (<48 hr) undergoing a cardioversion strategy with IV procainamide from 2017 to 2019 were reviewed. Clinical outcomes assessed included rates of cardioversion, hospital admission, stroke, and return ED visits for arrhythmia or serious adverse events. A total of 64 patients received procainamide therapy-60.9% achieved cardioversion and 35.9% were admitted to the hospital. The mean dose was 1062.4 mg (12.1 mg/kg). No patients returned to the ED secondary to stroke and 9.4% experienced complications attributed to procainamide, the most common being hypotension. Within 30 days of therapy, 20.3% of patients returned to the ED secondary to arrhythmia recurrence. Patients experiencing cardioversion with procainamide were less likely to be admitted to the hospital (25.6% vs. 52.0%; p = 0.04) or receive a rate control agent (17.9% vs. 64.0%; p = 0.001). There was no significant difference in the rate of 30-day return between those who experienced pharmacologic cardioversion and those who did not (p = 0.220). The implementation of a procainamide-based acute cardioversion strategy for patients presenting to the ED with recent-onset AF resulted in a 60% cardioversion rate, which was associated with a significantly higher rate of discharge from the ED. Transient hypotension was the most common adverse event. Further investigation into ED-based protocols for management of recent-onset AF is necessary to better understand their safety and efficacy.