Emergency Department Volume Research Articles

Potentially avoidable interfacility transfers following reduced emergency department volumes due to COVID-19 “Safer-at-Home” orders

ObjectivesWe sought to assess if a state-wide lockdown implemented due to COVID-19 was associated with increased odds of being a potentially avoidable transfer (PAT). MethodsWe conducted a retrospective observational analysis using hospital administrative data of interfacility ED-to-ED transfers to a single, quaternary care adult ED after “Safer at Home” orders were issued March 23rd, 2020 in [Blinded for submission]. Using the PAT classification to identify transfers rapidly discharged from the ED or hospital and may not require in-person care, we used a multivariable logistic regression model to examine the association of the lockdown order with odds of a transfer being a PAT. We compared the period January 1, 2018 to March 23, 2020 with March 24, 2020 to September 30, 2020, adjusting for seasonality, patient, and situational factors. ResultsThere were 20,978 ED-to-ED transfers from during this period that were eligible and 4806 (23%) that met PAT criteria. While the first month post-lockdown saw a decrease in PATs (28%), this was not sustained. In the multivariable model there was a significant seasonal effect; May through September had the highest number of transfers as well as PATs. After adjusting for seasonality, the lockdown was not associated with PATs (adjusted odds ratio [aOR] 0.99, 95% CI 0.2, 5.2) and PATs decreased over time. ConclusionsWe did not find an effect of the COVID-19 lockdown on PATs though there was a considerable seasonal effect and an overall downward trend in PATs over time.

Use of rational subgrouping to identify areas for improving time to ultrasound performance

Background: Safe, high-quality care within emergency departments includes the provision of efficient diagnostic and testing. At the Alberta Children’s Hospital, emergency department (ED) and radiology staff have anecdotally noted delays for some patients in the completion of abdominal and pelvic ultrasounds. Rational subgrouping is an approach that stratifies data into multiple groups for display in control charts to minimize in-group variability and maximize between-group variability. The aim of this project was to identify subgroups based on demographic factors, shift type, and disposition status that experience longer time to completion, in order to identify targeted areas for improvement. 
 Methods: A working group of interprofessional stakeholders was formed, including emergency physicians, an emergency QI nurse, a radiologist and a sonographer. Existing protocols were reviewed. These included recent changes that had been implemented but not yet systemically evaluated, including specifying ultrasound indications that require bladder filling, revising bladder filling protocols, specifying requirements for radiologist approval, and clarifying flow and communication processes.
 Abdominal and pelvic ultrasounds conducted in the Alberta Children’s Hospital ED from May 2019 to April 2021 were included. This range encapsulated data points both before and after the declaration of the COVID-19 pandemic on Mar 11, 2020, which notably reduced ED volumes. Time stamps were obtained from the electronic health record for the time of physician assessment, time of study request and the time of study result. Data was subdivided based on rational subgroups for (1) sex, (2) age (3) shift time availability, and (4) disposition status. Cases with excessive delay were identified and a chart review was conducted to confirm time stamp validity and to identify unique circumstances contributing to delay. An exemption for ethics board review was obtained from the Conjoint Health Research Ethics Board at the University of Calgary due to the primary purpose of the project being quality improvement.
 Evaluation Methods: Statistical process control charts (X-bar and S-chart) were used to establish mean and variation in time from ultrasound order to study result in the total population and each subgroup, measured in minutes. Scrotal ultrasounds were analyzed as a comparator to understand the most efficient time expected from ultrasound order to completion, given that they are typically highly prioritized. Rules to detect special causes were applied, including: (1) Single point outside control limits, defined as 3-sigma (2) Eight or more points above or below the centre line (mean) (3) Six consecutive points that are increasing (trend up) or decreasing (trend down) (4) Two out of three consecutive points near the outer third of a control limit (5) 15 consecutive points in the inner third nearest the centre line (mean).
 Results: The mean time from ordering an abdominal/pelvic ultrasound to having reported findings was 203 minutes, compared to 103 minutes for scrotal ultrasounds. The mean time from physician assessment to having a reported study was 279 minutes, compared to 135 minutes for scrotal ultrasounds. Using subgrouping by sex for abdominal/pelvic ultrasounds, females had an mean order to result time of 226 minutes, versus 178 minutes for males. For the 0 to 3 year age group, the mean order to result time was 167 minutes, which increased for ages 4 to 11 to 193 minutes and for children greater than 12 years old, it was 223 minutes. By shift type, day shifts had a mean order to result time of 157 minutes, evening shifts 142 minutes and night shifts 317 minutes. Using rational subgrouping for disposition status, the order to result time for admitted patients was shorter at 190 minutes compared to discharged patients, which was 214 minutes.
 Advice and Lessons Learned: 
 1) This initiative highlights the benefits of using rational subgrouping for emergency department quality improvement projects. By separating our data based on sex, age, time of care, and disposition status, considerable variability was revealed between subgroups that would have otherwise been hidden.
 2) Groups more likely to experience longer wait times for abdominal or pelvic ultrasounds included females, patients arriving at night, and adolescents.
 3) Rational subgrouping with baseline data enables a targeted approach when designing plan-do-study-act cycles.

Patterns of Emergency Medical Transport for Suspected Acute Stroke, Acute Myocardial Infarction, and Other Diagnoses During the COVID‐19 Pandemic: A Retrospective Analysis of a Large Hospital‐Based Emergency Medical Services Agency

Patterns of Emergency Medical Transport for Suspected Acute Stroke, Acute Myocardial Infarction, and Other Diagnoses During the COVID‐19 Pandemic: A Retrospective Analysis of a Large Hospital‐Based Emergency Medical Services Agency

Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis.

PurposePediatric sepsis guidelines recommend rapid intravenous fluid (IVF) bolus administration rates (BAR). Recent sepsis studies suggest that rapid BAR may be associated with increased morbidity. We aimed to describe the association between emergency department (ED) IVF BAR and clinical outcomes in pediatric sepsis.Patients and MethodsSecondary post-hoc analysis of retrospective cohort data from 19 hospitals in the Pediatric Septic Shock Collaborative (PSSC) database. Patients with presumed septic shock were defined by severe sepsis/septic shock diagnostic codes, receipt of septic shock therapies, or floor-to-ICU transfers within 12 hours from ED admission for septic shock. Patients (2 months–21 years) with complete data on weight, antibiotic receipt, bolus timing, and bolus volumes were included. The primary outcome was 30-day mortality. Associations between BAR and mortality and secondary (intubation or non-invasive positive pressure ventilation = NIPPV) outcomes were assessed using unadjusted and adjusted logistic regression.ResultsThe PSSC database included 6731 patients; 3969 met inclusion and received a median ED volume of 40.2 mL/kg. Seventy-six (1.9%) patients died, 151 (3.8%) were intubated, and 235 (5.9%) had NIPPV administered. The median BAR was 25.7 mL/kg/hr. For each 20 mL/kg/hr increase in BAR, the adjusted odds ratio (aOR) for 30-day mortality [aOR = 1.11 (95% CI 1.01, 1.23)], intubation [aOR = 1.25 (95% CI 1.09, 1.44)], and NIPPV [aOR = 1.20 (95% CI 1.05, 1.38)] significantly increased.ConclusionFaster ED IVF bolus administration rates in this pediatric sepsis database were associated with higher adjusted odds of death, intubation and NIPPV. Controlled trials are needed to determine if these associations are replicable.

Intimate Partner Violence, Sexual Assault, and Child Abuse Resource Utilization During COVID-19.

IntroductionKey measures in preventing spread of the virus that causes coronavirus disease 2019 (COVID-19) are social distancing and stay-at-home mandates. These measures along with other stressors have the potential to increase incidences of intimate partner violence (IPV), sexual assault, and child maltreatment.MethodsWe performed a retrospective review of county police dispatches, emergency department (ED) visits, Sexual Assault Nurse Examiner (SANE) consults, Domestic Violence Healthcare Project (DVHP) team consults, and Child Protection Team consults at a large, tertiary, Level I trauma center. We queried International Classification of Diseases Revision 10 codes most specific to IPV, sexual assault, and child maltreatment from March–October 2020 compared to 2019. Similarly, the number of consults performed by SANE, DVHP, and our Child Protection Team were collected. We compared all ED visits and consultations to total ED visits for the reviewed time period. Finally, the total number of calls and referrals to a child advocacy center and resource call line for victims were recorded during this timeframe.ResultsPolice dispatches for IPV-related assaults increased by 266 reports from 2019 to 2020 (P = 0.015). Emergency department visits related to IPV increased from 0.11% of visits in 2019 to 0.15% in 2020 (P = 0.032), and DVHP consults increased from 0.31% in 2019 to 0.48% in 2020 of ED visits in the first three months (P < 0.001). Child maltreatment visits increased from 0.47% of visits in 2019 to 0.81% of visits in 2020 (P = 0.028), and a higher percentage of patients required Child Protection team consults from 1% in 2019 to 1.6% in 2020 (P = 0.004). Sexual assault-related visits and SANE consults both showed a small increase that was not statistically significant. Fewer calls and referrals were made to our child advocacy center and resource call line, decreasing by 99 referrals and 252 calls, respectively.ConclusionDespite decreased ED volumes throughout the pandemic, we observed an increase in police dispatches, ED visits, and utilization of hospital consult services related to IPV and child maltreatment following the initiation of stay-at-home orders. However, use of community resources, such as the local child advocacy center, declined.

Minor traumatic injuries in the emergency department pre- and post-implementation of an emergency care access point.

In the Netherlands, out-of-hours General Practice Cooperatives (GPCs) increasingly collaborate with Emergency Departments (EDs) to form an Emergency Care Access Point (ECAP). ECAPs aim to decrease the number of low-urgent ED attendances, of which many compromise minor traumatic injuries. In this study, we evaluated the impact of ECAP implementation on the incidence of minor traumatic injuries in the ED. We evaluated a total of 2772 ED patients who presented with a minor traumatic injury (categorized into traumatic wounds and isolated extremity injuries) 1 year before and 1 year after ECAP implementation. We compared patient characteristics, throughput, diagnosis, treatment and follow-up before and after ECAP implementation. ECAP implementation was associated with a reduction in ED volume for minor traumatic injuries: -12.4% for isolated extremity injuries (1249 vs. 1094) and -74.6% for traumatic wounds (342 vs. 87). Multivariable logistic regression analysis controlling for patient characteristics showed that ECAP implementation was associated with higher rates of substantial injuries in the ED (OR 1.20, 95% CI = 1.01-1.43), and more patients requiring outpatient follow-up. Implementation of an ECAP was associated with a reduction of ED utilization by patients with minor traumatic injuries, traumatic wounds in particular. This healthcare intervention may therefore help to reduce ED utilization for low-urgent complaints.

Balance of Public Medical and Health Services and Reform of Medical Institutions Based on 5G Sensor Technology

Since its reform and opening in 1978, China’s economy has grown rapidly and human life and physical well-being have improved significantly. The public health care system is an imperative guarantee of people’s life and physical health. It is necessary to establish a reasonable planning, a reasonable division of labor, and an efficient medical service system to improve the overall efficiency of health care services and ensure the physical health of the people. The balance of public health care services plays a very important role. It plays a very important role in safeguarding people’s basic right to health, regulating social fairness and justice, promoting the sustainable development of medical and health services, and building a harmonious society. Based on 5G sensor technology, this paper combines relevant research on sensor technology at home and abroad and comprehensively uses related theories such as sensing principles and health care services to discuss the internal operation mechanism of China’s public health care service system. It conducts experiments to compare health care services with 5G sensor technology with existing health care service systems. It compares its bed occupancy rates, hospital admissions and discharges, outpatient and emergency department volumes, and average inpatient costs. It studies the impact of 5G sensor technology on public health care services. The experimental results show that after adopting 5G sensor technology, the average bed utilization rate in the H hospital is 88.71%. The total number of hospitalizations was 9.845 million, and the total number of discharges was 8.668 million. The total number of outpatient visits was 44.259 million, and the total emergency department was 7.694 million. The per capita cost of inpatients in H hospital is 15,840 yuan, and the per capita cost of inpatients in W center is 9,661.75 yuan.

Review: Impact of urgent youth outpatient mental health care on patient and health system outcomes - a scoping review.

Young people often face barriers to psychiatric care and are increasingly seeking crisis services for mental health issues through the emergency department (ED). Urgent psychiatric care models provide youth in crisis with rapid access to time-limited mental health care on an outpatient basis. This scoping review aims to evaluate the impact of such urgent psychiatric services for youth aged 13-25 on patient and health system outcomes. We conducted a literature search on PubMed, EMBASE, MEDLINE, PsycINFO, and the Cochrane Database of Systematic Reviews for studies published from inception to November 20, 2020. We included studies that described outpatient psychiatric services designed for youth aged 13 to 25, took place in a clinical setting, and offered any combination of assessment, treatment, and referral. We excluded studies describing suicide intervention programmes. Our search yielded six studies, four of which were descriptive studies and two of which were randomized controlled trials. Most studies found that access to urgent psychiatric care for youth was associated with reduced ED volumes, fewer health system costs, and fewer hospitalizations. None of the studies presented evidence that urgent psychiatric services are associated with improved patient symptomatology or functioning. The results of this scoping review highlight the scarcity of robust evidence evaluating the effectiveness of urgent care for youth mental health. Further experimental studies and a set of standardized quality measures for evaluating these services are needed to bridge this critical gap in mental health care for youth in crisis.

Trends in Lower Extremity Injuries Presenting to Emergency Departments During the COVID-19 Pandemic

BackgroundDuring the emergence of the SARS-CoV-2 (COVID-19) pandemic, there were substantial changes in U.S. emergency department (ED) volumes and acuity of patient presentation compared with more recent years. Objectives: The purpose of this study was to characterize the incidence of specific lower extremity (LE) injuries presenting to U.S. EDs during the COVID-19 pandemic and to analyze trends across age groups and rates of hospital admission compared with previous years. MethodsThe National Electronic Injury Surveillance System database was queried to identify patients who presented to U.S. EDs for a LE orthopedic injury between 2016 and 2020. ResultsThese queries returned 252,656 cases, representing a total estimate of 9,740,514 injuries presenting to EDs across the United States. The mean incidence of LE orthopedic injuries was 596.8 injuries per 100,000 person-years (95% confidence interval [CI] 594.9–598.7), with the greatest annual decrease in incidence occurring between 2019 and 2020 (24.96%). The largest number of estimated hospital admissions occurred in 2020, with a total 181,671 admissions (95% CI 178,032–185,311), a 25.74% increase from the average number of admissions between 2016 and 2019. ConclusionThe COVID-19 pandemic has placed immense stress on both emergency medical services and hospital systems around the United States. While there were decreased rates of ED utilization for LE orthopedic complaints during the first year of the pandemic, there was a concomitant increase in both the number and proportion of these injuries admitted to the hospital from the ED. This places an additional burden on already stressed emergency medicine services and overall hospital systems that could slow down the management of medical emergencies.

Evaluation of emergency department visits for mental health complaints during the COVID-19 pandemic.

BackgroundThe COVID‐19 pandemic has resulted in over 6 million deaths worldwide as of March 2022. Adverse psychological effects on patients and the general public linked to the pandemic have been well documented.MethodsWe conducted a retrospective analysis of adult emergency department (ED) encounters with diagnoses of anxiety, depression, and suicidal ideation using International Classification of Diseases, Tenth Revision (ICD‐10) codes at a tertiary care hospital in New York City from March 15 through July 31, 2020 and compared it with ED encounters during the same time period in the previous 3 years (2017–2019). The relative risk (RR) of these diagnoses was calculated comparing a prepandemic sample to a pandemic sample, accounting for total volume of ED visits.ResultsA total of 2816 patient encounters met the inclusion criteria. The study period in 2020 had 31.5% lower overall ED volume seen during the same time period in the previous 3 years (27,874 vs average 40,716 ED encounters). The risk of presenting with anxiety during the study period in 2020 compared to prior 3 years was 1.40 (95% confidence interval [CI] 1.21–1.63), for depression was 1.47 (95% CI 1.28–1.69), and for suicidal ideation was 1.05 (95% CI 0.90–1.23). There was an increase in admissions for depression during the pandemic period (15.2% increase, 95% CI 4.6%–25.7%).ConclusionThere was a relative increase in patients presenting to the ED with complaints of anxiety and depression during the height of the COVID‐19 pandemic, while absolute numbers remained stable. Our results highlight the importance of acute care‐based mental health resources and interventions to support patients during this pandemic.

Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations

Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.

Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods

ObjectiveNew York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year. MethodsRetrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019–December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20–6/7/20) and late (6/8/20–12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events. ResultsThere was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)]. ConclusionsNYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.

Methodological approaches to measuring the incidence of unplanned emergency department presentations by cancer patients receiving systemic anti-cancer therapy: a systematic review

BackgroundThe need to mitigate the volume of unplanned emergency department (ED) presentations is a priority for health systems globally. Current evidence on the incidence and risk factors associated with unplanned ED presentations is unclear because of substantial heterogeneity in methods reporting on this issue. The aim of this review was to examine the methodological approaches to measure the incidence of unplanned ED presentations by patients receiving systemic anti-cancer therapy in order to determine the strength of evidence and to inform future research.MethodsAn electronic search of Medline, Embase, CINAHL, and Cochrane was undertaken. Papers published in English language between 2000 and 2019, and papers that included patients receiving systemic anti-cancer therapy as the denominator during the study period were included. Studies were eligible if they were analytical observational studies. Data relating to the methods used to measure the incidence of ED presentations by patients receiving systemic anti-cancer therapy were extracted and assessed for methodological rigor. Findings are reported in accordance with the Synthesis Without Meta-Analysis (SWiM) guideline.ResultsTwenty-one articles met the inclusion criteria: 20 cohort studies, and one cross-sectional study. Overall risk of bias was moderate. There was substantial methodological and clinical heterogeneity in the papers included. Methodological rigor varied based on the description of methods such as the period of observation, loss to follow-up, reason for ED presentation and statistical methods to control for time varying events and potential confounders.ConclusionsThere is considerable diversity in the population and methods used in studies that measure the incidence of unplanned ED presentations by patients receiving systemic anti-cancer therapy. Recommendations to support the development of robust evidence include enrolling participants at diagnosis or initiation of treatment, providing adequate description of regular care to support patients who experience toxicities, reporting reasons for and characteristics of participants who are lost to follow-up throughout the study period, clearly defining the outcome including the observation and follow-up period, and reporting crude numbers of ED presentations and the number of at-risk days to account for variation in the length of treatment protocols.

Prevalence of Adverse Childhood Experiences in a Pediatric Emergency Department: Support for Trauma-Informed Pediatric Emergency Care.

Data from the 2019 National Survey of Children's Health revealed that 39.8% of children in the United States have been exposed to adverse childhood experiences (ACEs), which are risk factors for long-term negative health outcomes. This study aimed to determine the prevalence of ACE exposure in a pediatric emergency department (ED) patients and describe the association between ACE exposure and ED recidivism. Five hundred children aged 0 to 17 years were evaluated for ACE exposure in an academic, urban, tertiary-care, pediatric ED via convenience sampling. The 2019 National Survey of Children's Health section on ACEs was administered to define ACE exposure. A prospective chart review was conducted on all children enrolled in the study to collect data on ED utilization for 1-year postsurvey. The relationship between ACE exposure and ED recidivism was examined by calculating relative risk. We found that 40.2% (confidence interval [CI], 36.5%-45.3%) of respondents had ACE exposure. The most frequently reported ACEs were poverty (20.8%; CI, 17.3%-24.6%), divorce/separation (18.2%; CI, 14.9%-21.9%), and mental illness within the household (7.2%; CI, 5.1%-9.8%). Adverse childhood experience exposure in this pediatric ED was similar to the national prevalence. There was no significant relationship between ACE exposure and high ED recidivism as an adverse outcome. Adverse childhood experience exposure in this population matched the prevalence reported in the national population. Our results suggest that this group is particularly important when mitigating these risk factors for long-term adverse health outcomes. Adverse childhood experience exposure did not appear to impact recidivism in a period of unprecedented low ED volumes during the coronavirus disease pandemic.

Impact of the COVID-19 Pandemic on the Severity of Diabetic Ketoacidosis Presentations in a Tertiary Pediatric Emergency Department.

Introduction:More severe presentations of diabetic ketoacidosis (DKA) have been reported during the coronavirus disease 2019 (COVID-19) pandemic, possibly due to avoidance of healthcare settings or reduced access to care. To date, no studies have utilized statistical process control to relate temporal COVID-19 events with DKA severity. Our objectives were (1) to determine whether the severity of pediatric DKA presentations changed during COVID-19 and (2) to temporally relate changes in severity with regional pandemic events.Methods:This study was a retrospective chart review of 175 patients younger than 18 years with DKA presenting to a pediatric emergency department in the United States between 5/1/2019 and 8/15/2020. As part of our ongoing clinical standard work in ED management of DKA, DKA severity measures, including presenting pH, the proportion of PICU admissions, and admission length of stay, were analyzed using statistical process control.Results:During COVID-19, we found special cause variation with a downward shift in the mean pH on DKA presentation from 7.2 to 7.1 for all patients. The proportion of DKA patients requiring PICU admission increased from 34.2% to 54.6%. Changes temporally corresponded to the statewide bans on large events (3/11/2020), school closures (3/13/2020), and a reduction in our institution’s emergency department volumes. Admission length of stay was unchanged.Conclusions:Pediatric DKA presentations were more severe from March to June 2020, correlating with regional COVID-19 events. Future quality improvement interventions to reduce delayed presentations during COVID-19 surges or other natural disasters should target accessibility of care and public education regarding the importance of timely care for symptoms.

Impact of COVID-19 on the Incidence and Severity of Obstetric and Gynecologic Emergency Department Visits in an Integrated Health Care System.

COVID-19 has had an unprecedented impact on medical care use and delivery, including stark reductions in emergency department (ED) volume. The aim of this study was to assess changes in incidence of OB/GYN ED visits and disease severity at time of presentation during the COVID-19 pandemic. We conducted a multicenter retrospective study of OB/GYN-related ED visits before and during the COVID-19 pandemic. Incidence rates (IRs) and severity measures were compared across time periods and years. A total of 18,668 OB/GYN ED encounters occurred between January 1 and December 31, 2020, compared to 21,014 encounters between January 1 and December 31, 2019. During shelter-in-place, visits decreased by 41% compared to the pre-pandemic period in 2020 before returning to typical rates (incidence rate ratio (IRR) = 0.98 in fall/winter). We found a similar proportion of patients with hemoglobin < 7 g/dL for diagnoses associated with bleeding and patients with white blood cell count > 12,000 per µL in the setting of infection comparing corresponding time periods in 2019 and 2020. There were fewer formal OB/GYN consults, hospital admissions at time of presentation, and urgent surgical procedures performed across all periods in 2020; however, hospitalization within 7 days substantially increased in the first half of 2020. The incidence of OB/GYN ED visits declined substantially between March and August 2020 but then returned to pre-pandemic levels by fall/winter 2020. The decreased incidence was not accompanied by an increase in severity of presentation.

Prehospital emergency department care activations during the initial COVID-19 pandemic surge.

To describe trends in prehospital presentations of critical medical and trauma conditions during the COVID-19 pandemic using prehospital and emergency department (ED) care activations. Observational analysis of ED care activations in a tertiary, urban ED between March 10, 2020 and September 1, 2020 was compared to the same time periods in 2018 and 2019. ED care activations for critical medical conditions were classified based on clinical indication: undifferentiated medical, trauma, or stroke. The primary outcomes were the number of patients presenting from the prehospital setting with specified ED activation criteria, total ED volume, ambulance arrival volume, and volume of COVID-19 hospital admissions. Locally weighted scatterplot smoothing curves were used to visually display our results. There were 1,461 undifferentiated medical activations, 905 stroke activations, and 1,478 trauma activations recorded, representing absolute decreases of 11.3, 28.1, and 20.3 percent, respectively, relative to the same period in 2019, coinciding with the declaration of a public health emergency in Connecticut. For all three types of presentation, post-peak spikes in activations were observed in early May, approximately two weeks after our health system in Connecticut reached its peak number of COVID-19 hospitalizations-eg, undifferentiated medical activations: increase in 280 percent, n = 140 from 2019, p < 0.0001-and declined thereafter, reaching a nadir in early June 2020. After the announcement of public health measures to mitigate COVID-19, ED care activations declined in a large Northeast academic ED, followed by post-peak surges in activations as COVID- 19 cases decreased.

Differences Between Emergency Medicine Residency Programs That Accept the Comprehensive Osteopathic Medical Licensing Examination of the United States and Those That Prefer or Only Accept the United States Medical Licensing Examination.

IntroductionThe Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) is a three-part series of examinations similar to the United States Medical Licensing Examination (USMLE) that osteopathic medical students must pass for medical licensure. Osteopathic students are not required to take the USMLE, but during the residency admission process, many emergency medicine (EM) residency programs will not consider osteopathic applicants who only take the COMLEX-USA. Therefore, we examined program-level characteristics between programs that accept the COMLEX-USA alone for osteopathic applicants and those that prefer the USMLE using free, publicly available online databases and residency program websites.MethodsEmergency Medicine Residents’ Association (EMRA) Match was the primary database used; however, missing exam preferences were supplemented from Fellowship and Residency Electronic Interactive Database Access (FREIDA) and individual program websites. Program characteristics were compared between EM residencies that accept the COMLEX-USA and those that prefer the USMLE using the Chi-square test for categorical variables and the Mann-Whitney test for interval variables.ResultsTwo hundred sixty of the 278 EM programs in the dataset were included in the analyses. One hundred and seven programs reported preferring the USMLE, while 151 reported accepting the COMLEX-USA alone. Programs differed by the educational environment of the primary training site (p <0.001), number of Standardized Letter(s) of Evaluation (SLOE) needed for an interview (p = 0.042), emergency department (ED) shift length (p = 0.021), former American Osteopathic Association accreditation (p <0.001), percentage of osteopathic residents (p <0.001), annual ED volume (p = 0.001), number of intern positions (p <0.001), and number of elective weeks (p = 0.028).ConclusionEM residency programs that reported accepting the COMLEX-USA alone for osteopathic applicants differed from those that prefer the USMLE. Therefore, osteopathic medical students interested in EM should consider these differences when deciding whether to take the USMLE.

Trends in upper extremity injuries presenting to emergency departments during the COVID-19 pandemic

IntroductionDuring the emergence of the SARS-CoV-2 (COVID-19) pandemic, there were substantial changes in United States (U.S.) emergency department (ED) volumes and acuity of patient presentation compared to more recent years. Thus, the purpose of this study was to characterize the incidence of specific upper extremity (UE) injuries presenting to U.S. EDs during the COVID-19 pandemic and analyze trends across age groups and rates of hospital admission compared to years prior. MethodsThe National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to U.S. EDs for an UE orthopaedic injury between 2016 and 2020. Chi-square analysis and logistic regression were used to assess for differences in ED presentation volume and hospital admissions between pre-pandemic (2016 through 2019) and during-pandemic (2020) times. ResultsThese queries returned 285,583 cases, representing a total estimate of 10,452,166 injuries presenting to EDs across the U.S. The mean incidence of UE orthopaedic injuries was 640.2 (95% CI, 638.2–642.3) injuries per 100,000 person-years, with the greatest year to year decrease in incidence occurring between 2019 and 2020 (20.1%). The largest number of estimated admissions occurred in 2020, with a total 135,018 admissions (95% CI, 131,518–138,517), a 41.6% increase from the average number of admissions between 2016 and 2019. ConclusionThere was a 20.1% decrease in the incidence of UE orthopaedic injuries presenting to EDs after the start of the COVID-19 pandemic with a concomitant 41.2% increase in the number of hospital admissions from the ED in 2020 compared to recent pre-pandemic years. We speculate that at least some elective, semi-elective or urgent ambulatory surgeries were canceled or delayed due to the pandemic and were subsequently directed to the ED for admission. Regardless of the cause of increased UE orthopaedic admissions, policy planners and administrators should be aware of the additional stresses placed on already burdened ED and inpatient services. Level of evidenceLevel III – Retrospective Cohort Study.

Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact.

Data suggest that low tidal volume ventilation (LTVV) initiated in the emergency department (ED) has a positive impact on outcome. This systematic review and meta-analysis quantify the impact of ED-based LTVV on outcomes and ventilator settings in the ED and ICU. We systematically reviewed MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, references, conferences, and ClinicalTrials.gov. Randomized and nonrandomized studies of mechanically ventilated ED adults were eligible. Two reviewers independently screened abstracts. The primary outcome was mortality. Secondary outcomes included ventilation duration, lengths of stay, and occurrence rate of acute respiratory distress syndrome (ARDS). We assessed impact of ED LTVV interventions on ED and ICU tidal volumes. The search identified 1,023 studies. Eleven studies (n = 12,912) provided outcome data and were meta-analyzed; 10 additional studies (n = 1,863) provided descriptive ED tidal volume data. Overall quality of evidence was low. Random effect meta-analytic models revealed that ED LTVV was associated with lower mortality (26.5%) versus non-LTVV (31.1%) (odds ratio, 0.80 [0.72-0.88]). ED LTVV was associated with shorter ICU (mean difference, -1.0; 95% CI, -1.7 to -0.3) and hospital (mean difference, -1.2; 95% CI, -2.3 to -0.1) lengths of stay, more ventilator-free days (mean difference, 1.4; 95% CI, 0.4-2.4), and lower occurrence rate (4.5% vs 8.3%) of ARDS (odds ratio, 0.57 [0.44-0.75]). ED LTVV interventions were associated with reductions in ED (-1.5-mL/kg predicted body weight [PBW] [-1.9 to -1.0]; p < 0.001) and ICU (-1.0-mL/kg PBW [-1.8 to -0.2]; p = 0.01) tidal volume. The use of LTVV in the ED is associated with improved clinical outcomes and increased use of lung protection, recognizing low quality of evidence in this domain. Interventions aimed at implementing and sustaining LTVV in the ED should be explored.