Emergency Severity Index Research Articles

Racial differences in treatment among patients with acute headache evaluated in the emergency department and discharged home

BackgroundPrior research has demonstrated the widespread presence of racial disparities in emergency department (ED) care and analgesia. We hypothesized that racial disparities continue to exist in ED analgesic prescribing patterns, time to analgesia, and time to provider in the treatment of headache. MethodsWe performed a retrospective cohort study of patients presenting to a large tertiary academic ED with chief complaint of headache. A structured medical record review was conducted to abstract relevant variables of interest. Patient race was categorized as white or Black, Indigenous, or person of color (BIPOC). Descriptive statistics were used to characterize the cohort and stratified analyses were conducted based on patient race and our key outcome measures of analgesic prescribing patterns, time to analgesia, and time to provider in the treatment of headache. ResultsWhite patients were more likely to be assigned an Emergency Severity Index score 2 or 3 and their BIPOC counterparts were more likely to be assigned an ESI score 3 or 4 (p = 0.02). There was no significant difference by race in time to analgesia (p = 0.318), time to provider (p = 0.358), or time to first medication treatment (p = 0.357). However, there were clear differences in prescribing patterns. BIPOC patients were significantly more likely to be treated with acetaminophen (p = 0.042) or ibuprofen (p = 0.015) despite reporting higher pain levels during triage (p < 0.001). White patients were significantly more likely to receive a head CT scan (p < 0.001) or neurology consult (p = 0.003) than their BIPOC counterparts. ConclusionRacial disparities persist in assessment and type of analgesia for patients being treated for headache in a large academic emergency department.

Patterns in emergency department unscheduled return visits during the COVID-19 pandemic

IntroductionFear surrounding nosocomial infections, expanded telehealth, and decreases in ED (emergency department) utilization altered the way patients sought emergency care during the COVID pandemic. This study aims to evaluate COVID-19's impact on the frequency and characteristics of unscheduled return visits (URVs) to the adult and pediatric ED. MethodsIn this retrospective cohort study, the electronic medical record was used to identify ≤9-day URVs at a tertiary adult and pediatric ED from 4/16/19–2/29/20 (control) and 4/16/20–2/28/21 (COVID). The primary outcome, proportion of total ED visits made up by URVs, and secondary outcomes, patient characteristics (age), illness acuity (emergency severity index (ESI)), disposition, and mortality were compared between the cohorts. Pediatric and adult data were analyzed separately. A sub-analysis was performed to exclude patients with suspected respiratory infections. ResultsFor adults, n = 4265, there was no significant difference between the proportion of ED census made up by URVs (4.56% (control) vs 4.76% (COVID), p = 0.17), mean patient age (46.33 (control) vs 46.18 (COVID), p = 0.80), ESI acuity (2.95 (control) vs 2.95 (COVID), p = 0.83), disposition (admission 0.32% (control) vs 0.39% (COVID), p = 0.69), and mortality (0.23% (control) and 0.49% (COVID), p = 0.15). When excluding possible respiratory infections comparisons remained insignificant.For pediatrics, n = 1214, there was a significant difference in the proportion of ED census made up by URVs (4.83% (control) to 3.55% (COVID), p < 0.01), age (5.52 (control) vs 6.43 (COVID), p = 0.01), and ESI acuity (3.31 (control) vs 3.17 (COVID), p < 0.01). There was no difference in disposition (admission 0.12% (control) vs 0% (COVID), p = 1). When excluding possible respiratory infections acuity (p = 0.03) remained significant. ConclusionIn the adult population, COVID did not significantly alter any of our outcomes. For pediatric patients, a decrease in the proportion of URVs and increase in acuity during COVID suggests that patients may have had other means of accessing care, avoided the ED, received more adequate care at initial presentation, or represented when more acutely ill.

Provider-Only Patients: A Novel Approach to ED Volume Surge and Covid-19

Summary To address changes in the health care landscape precipitated by the Covid-19 pandemic, particularly the lack of health care personnel, the ED at Inova Fairfax Hospital developed a process to evaluate and treat patients under a Provider-Only Patients (POP) protocol involving only physicians or advanced practice providers (APPs). In this article, Inova reports on the development of the POP process and the outcomes of a cohort of patients with suspected Covid-19 who were seen in the ED as POP patients between December 1, 2021, and January 15, 2022. All of the POP patients had Covid-19–related complaints, had an Emergency Severity Index (ESI) of 4 or 5 (on a scale where 1 is most urgent and 5 is least urgent), required limited nursing intervention, were discharged, and were 21–64 years of age. Any patients who exhibited signs of hemodynamic instability (e.g., hypo- or hypertensive), had non–Covid-19 complaints, had room air oxygen saturation below 96%, were pregnant, had difficulty ambulating, and/or had inadequate social support were not considered to be a POP patient and were seen in the regular queue of patients. Inova developed a designated area in the ED where patients were seen and discharged directly by the provider. Patients were first triaged by a triage nurse or physician to determine POP status. As of January 2022, Inova’s ED had seen 640 POP and 2,386 non-POP ESI 4 and 5 subjects (4.4% of the total ED census). Although the mean time from ED arrival to bed favored non-POP patients by approximately 9 minutes, the mean time from initially being seen by a provider to the discharge disposition and the mean time from discharge disposition placement to leaving the ED significantly favored POP by 48 minutes and 66 minutes, respectively. No POP patients returned within 72 hours for admission to the hospital, which supports the integrity of the POP triage and care delivery process. The authors estimate that the 640 patients who were part of the POP process saved approximately 1,892.27 nursing and 705.1 provider hours during that 46-day study period. No additional physician or APP hours were required, which suggests that POP is a safe, efficient, and effective process that can significantly reduce provider-to-disposition times and overall discharge length of stay. In addition to its value in mitigating the pandemic-related staff shortage, the POP model may also be considered to address nonpandemic-related staffing challenges.

Evaluation of the Validity and Reliability of ANKUTRIAGE, a New Decision Support System in Pediatric Emergency Triage.

The intensity of emergency services is an increasing health problem all over the world, necessitating an effective triage system. The aim of this study was to evaluate the validity and reliability of the "ANKUTRIAGE" in children. This prospective, longitudinal study was carried out at a pediatric emergency department. ANKUTRIAGE, a 5-level computer-aided triage decision support system, was developed. Patients younger than 18 years who do not need emergency intervention, who had complete vital sign measurements, who gave consent for the study, and who were admitted to the emergency service during working hours with trained personnel were included. For validity, agreement between the urgency levels determined by ANKUTRIAGE and the reference triage systems: Pediatric Canadian Triage and Acuity Scale and Emergency Severity Index, was evaluated. In addition, the association of urgency levels with clinical outcomes was studied. To assess reliability, patients were evaluated by 2 blinded healthcare professionals using ANKUTRIAGE and a quadratic weighted κ was estimated. A total of 1232 children with a median age of 4.00 years were included. ANKUTRIAGE acuity levels significantly correlated with the number of resources used, the number of patients undergoing life-saving procedures, pediatric intensive care unit, and overall hospitalization rates, respectively ( P < 0.001, P < 0.001, P < 0.001, P < 0.001). The agreement of ANKUTRIAGE with Pediatric Canadian Triage and Acuity Scale was found to be 0.94 (95% confidence interval [CI], 0.93-0.94), with an Emergency Severity Index of 0.75 (95% CI, 0.70-0.80). The interrater agreement between 2 evaluators who used ANKUTRIAGE reflected as excellent consistency 0.92 (95% CI, 0.89-0.95; κ > 0.8). ANKUTRIAGE demonstrated high agreement with clinical outcomes and with proven triage systems and reflected high reliability between users. ANKUTRIAGE will enable a more standardized and practical triage, especially in crowded pediatric emergency departments and in situations where triage is performed by health professionals with different experience and professions.

Patient disposition using the Emergency Severity Index: a retrospective observational study at an interdisciplinary emergency department

ObjectivesEarly patient disposition is crucial to prevent crowding in emergency departments (EDs). Our study aimed to characterise the need of in-house resources for patients treated in the ED according to...

Do racial disparities exist at various time points during an emergency department visit for chest pain

IntroductionIt is well documented that disparities in patient care based on race and ethnicity are prevalent in the emergency medical care setting. In most cases these evaluations are patient focused and outcome based. The timeliness of patient treatment in the emergency department (ED) is correlated with patient outcomes. In this study, we sought to evaluate whether the timeliness of care for patients with chest pain across stages of care was impacted by patient race. MethodsThis was a retrospective evaluation of ED throughput times including adults who presented to one of seventeen EDs in a large healthcare system from January 1, 2019 to December 31, 2019 and met criteria for inclusion. The effect of race on different intervals of care were assessed. Generalized Linear Models were used to estimate the effect of race on different intervals of care while controlling for Charlson Comorbidity index, age, gender, insurance, ED facility type and emergency severity index acuity level. ResultsA total of 28,705 patients were included, with a mean age of 54 ± 18 years. The majority of patients were White (63%), female (56%) and had Medicare or Medicaid (56%). Black patients experienced significantly increased wait times for resident physician examination, advanced practice provider examination, attending physician examination, and ED disposition. There was no difference in time to triage between Black patients and White patients. ConclusionBlack patients have longer wait times for resident physician evaluation, advanced practice provider evaluation, attending physician evaluation, and ED disposition when presenting to the ED with chest pain.

The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older.

ObjectiveTo validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI).MethodsProspective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS.ResultsIn the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model.ConclusionThe CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.

A Comparative Analysis of Hospital Triage Systems in the Geriatric Adult Trauma Patients: A Quality Improvement Pilot Study.

The objective of our study is to compare the predicted hospital admission disposition based on the level of risk as determined by the modified Trauma-Specific Frailty Index (mTSFI) score with those determined by arbitrary decisions made based on the Emergency Severity Index (ESI) severity level. We surveyed 100 trauma patients ages 50 and older, admitted to a level 1 trauma center between April 2019 and July 2019. We retrospectively reviewed the hospital admission disposition of each patient under the ESI, which was then compared to the mTSFI-predicted hospital admission disposition. The mTSFI scores were calculated by surveying each patient. Statistical analysis was performed to identify any statistical significance of concordance and discordance when comparing the mTSFI and ESI. The average age was 57.6 ± 4.2 years old in the non-geriatric group vs 76.3 ± 7.3 years old in the geriatric group. There was a male predominance in both groups (61% vs 69.5%). The mTSFI identified a higher percentage of triage discordance in the non-geriatric group (73%) compared to the geriatric cohort (53%) (95% difference CI, [39.6-40], P = .05). Non-geriatric patients have higher recorded rate of frailty than previously recognized and screening should begin at age 50, not 65. The mTSFI may be an effective tool to appropriately triage adult trauma patients at increased risk due to frailty and may reduce in-hospital complications.

Comparison the Emergency Severity Index and Manchester Triage System in Trauma Patients.

Objective:To compare the emergency severity index (ESI) and Manchester triage system (MTS) in trauma patients.Methods:This cross-sectional study was conducted by census method in Hasheminejad hospital during 2019. Patients referred to a trauma center triaged by five trained triage nurses based on ESI and MTS. Outcomes were considered as length of stay at the emergency department, admission to the other sectors and discharge or leave the hospital. Information from the triage form, nursing registry office and hospital registry system were extracted and analyzed by SPSS software.Results:Totally 447 and 468 patients triaged with the ESI and MTS were included, respectively. Seventy percent of patients triaged with ESI and 34% with MTS were placed in level 3 or the yellow group (equivalent group 3 triage). The hospitalization rate is approximately equal at each triage level in the both systems. The mortality rate in both groups was 0%. Mean length of stay was significantly lower in the MTS group compared to ESI in the emergency department (p<0.05).Conclusion:Using of ESI triage in the trauma center causes to arrive more patients to the emergency department instead of the fast track and leads to waste the time and energy of staff’. However, further studies are needed to prove this result.

Triaging patients prior to the arrival of the mass casualty: Emergency Severity Index equivalency to SALT disaster triage.

To compare the Emergency Severity Index (ESI) and Sort Assess Life Saving Interventions Treatment and Transport (SALT) triage categories for an existing emergency department (ED) patient population. A prospective, cross-sectional study. An academic-affiliated community teaching ED at a Level 1 Trauma Center. All patients presenting to the ED over 2 nonconsecutive 24-hour weekdays. The correlation between triage system classifications was assessed using the Spearman's rank correlation coefficient. 100 percent of ESI 5, 83.3 percent of ESI 4, and 70.4 percent of ESI 3 were categorized as Minimal under SALT. 70.8 percent of ESI 2 was categorized as Delayed, and 71.4 percent of ESI 1 designations correlated with Immediate. Spearman's rank correlation coefficient was 0.509 (p < 0.001). This study results suggest that ESI moderately correlates with SALT, particularly in lower acuity patients. This result may inform future protocol development for rapid triage of existing ED populations prior to the arrival of patients from a mass casualty event.

In-hospital pediatric patient transfers to the pediatric emergency department

Purpose: The aim of this study was to determine whether the clinical features of the cases referred from in-hospital areas to the pediatric emergency department (ED) with “reverse transport” have emergency characteristics and the reasons for the transfer, and to contribute to intra-hospital transfer protocols to be prepared. &#x0D; Materials and Methods: This is a retrospective cohort study. The clinical properties of 120 patients who were sent to the ED from the hospital area were evaluated. &#x0D; Results: 57.5% (69) of the patients were male and the median age was 42 months (0-210 months). 45.8% (55) were referred to the ED because their clinical condition required emergency treatment. 54.8% of these patients were stable according to Pediatric Assessment Triangle (PAT) and 78.6% were category 3, 4, 5 according to Emergency Severity Index (ESI). Only 4 patients received ESI life-saving procedures. 70% (84) were treated in the ED. There was a statistically significant difference between the PAT and ESI and the group of patients whose clinical status needed urgent treatment.&#x0D; Conclusion: Most of the patients sent to PED from other wards within the hospital are stable patients. For the effective use of the PED, the patients who will be transferred to the PED should be carefully evaluated by the relevant physician, priority should be given to the transport of hemodynamically unstable patients to the emergency room, and they should be treated appropriately in short-term follow-up or treatment units. For stable patients, an area independent from the emergency department should be created in line with the facilities of each hospital.

Effect of age adjustment on two triage methods

BackgroundMost emergency departments rely on acuity assessment, triage, to recognize critically ill patients that need urgent treatment, and to allocate resources according to need. The accuracy of commonly used triage instruments such as the Emergency Severity Index (ESI) is lower for older adults compared to young patients. We aim to examine, whether adjusting the triage category by age leads to improvement in sensitivity without excessive increase in patient numbers in the higher triage categories. The primary outcome measure was 3-day mortality and secondary outcomes were 30-day mortality, hospital admission, and HDU/ICU admissions.MethodsWe gathered data of all adult patients who had an unscheduled visit to any of our three emergency departments within one month. The data was analysed for 3-day mortality, 30-day mortality, hospital admission, and high dependency unit or intensive care unit (HDU/ICU) admission. The analysis was run for both the standard ESI triage method and a local 3-level Helsinki University Hospital (HUH) method. A further analysis was run for both triage methods with age adjustment. Net reclassification improvement values were calculated to demonstrate the effect of age adjustment.ResultsThirteen thousand seven hundred fifty-nine patients met the study criteria, median age was 57. 3-day mortality AUCs for unadjusted HUH and ESI triage were 0.77 (0.65–0.88) and 0.72 (0.57–0.87); 30-day mortality AUCs were 0.64 (0.59–0.69) and 0.69 (0.64–0.73); hospital admission AUCs were 0.60 (0.68–0.71) and 0.66 (0.65–0.68) and HDU/ICU admission AUCs were 0.67 (0.64–0.70) and 0.82 (0.79–0.86), respectively. Age adjustment improved accuracy for 30-day mortality and hospital admission. With the threshold age of 80, AUCs for 30-day mortality were 0.73 (0.68–0.77) and 0.77 (0.73–0.81) and for hospital admission, 0.66 (0.65–0.67) and 0.72 (0.71–0.73) for the HUH and ESI triage. The effect was similar with all cut off ages.ConclusionMoving older adults into a more urgent triage category based on age, improved the triage instruments’ performance slightly in predicting 30-day mortality and hospital admission without excessive increase in patient numbers in the higher triage categories. Age adjustment did not improve HDU/ICU admission or 3-day mortality prediction.

Comparing the prehospital NEWS with in-hospital ESI in predicting 30-day severe outcomes in emergency patients

BackgroundIn Iran, the emergency departments (EDs) have largely adopted the emergency severity index (ESI) to prioritize the emergency patients, however emergency medical services (EMS) mainly triage the patients based on the paramedics’ gestalt. The National Early Warning Score (NEWS) is a recommended prehospital triage in the UK. We aimed to compare prehospital NEWS and ED ESI for predicting severe outcomes in emergency patients.MethodsAn observational study was conducted in a university-affiliated ED between January and April 2021. Adult patients who arrived in the ED by EMS were included. EMS providers calculated the patients' NEWS upon arriving on the scene using an Android NEWS application. In the ED, triage nurses utilized the ESI algorithm to prioritize patients with higher clinical risk. Then, Research nurses recorded patients' 30-day severe outcomes (death or ICU admission). Finally, The prognostic properties of ESI and NEWS were evaluated.ResultsOne thousand forty-eight cases were included in the final analysis, of which 29 (2.7%) patients experienced severe outcomes. The difference between the prehospital NEWS and ED ESI in predicting severe outcomes was not statistically significant (AUC = 0.825, 95% CI: 0.74–0.91 and 0.897, 95% CI, 0.83–0.95, for prehospital NEWS and ESI, respectively).ConclusionOur findings indicated that prehospital NEWS compares favorably with ED ESI in predicting 30-day severe outcomes in emergency patients.

Characteristics and Demographics of Patients Requiring Emergent Air Medical.

Background As integrated health systems become more common, interfacility patient transfers will increase and air transport programs will be prioritized. Understanding characteristics of patients triaged to air medical transport will assist with resource allocation and needs assessment. The objective of this study was to investigate the demographics and clinical characteristics of patients that presented to the emergency department (ED) and subsequently required emergent air medical interfacility transport. Methods This was a retrospective, multicenter study conducted at eight hospitals within Northwell Health, the largest academic health system in New York state. The study was conducted between December 1, 2014, and July 31, 2020, and included patients who presented to an ED and subsequently required emergent air medical interfacility transport. Results Overall, the median age was 37 years (IQR 4–66), and 231 (54%) subjects were males. The majority of subjects (59%) had no reported comorbidities, arrived by ambulance (52%), and were emergency severity index triage 2 (48%). Frequent indications for transfer were nontraumatic neurologic (37%), pulmonary or respiratory (13%), trauma (12%), and cardiovascular (12%). Most patients were not ventilated before transport (71%). The median time to call for transport at the sending institution was 2:42 hours (IQR 1:14–6:54), and the median length of stay was 4:12 (IQR 2:31–8:48). Most patients were subsequently admitted (96%) at the receiving institution to an intensive care unit (72%). Conclusions This study describes patients' demographic and clinical characteristics who required emergent air medical transport. Helicopter transport is costly, and data from these patients may further help our understanding of who is transported by air and how important air transport is to the health system.

A modified emergency severity index level is associated with outcomes in cancer patients with COVID-19

ObjectiveTo evaluate a modified emergency severity index (mESI)-based triage of cancer patients with coronavirus disease 2019 (COVID-19) in the emergency department (ED) and determine the associations between mESI level and ED disposition, hospital length of stay, and overall survival. MethodsMedical records were retrospectively reviewed for all patients who presented to our institution's ED between March 22, 2020, and March 12, 2021, and tested positive for SARS-CoV-2. ResultsA total of 306 cancer patients tested positive for SARS-CoV-2, with 45% of patients triaged to level 2 (emergent) and 55% to level 3 (urgent). Among all patients, 61.8% were admitted to the hospital, 15.7% were admitted to the intensive care unit, 2.9% were sent for observation, and 19.6% were discharged. Although demographic and clinical characteristics did not significantly vary by triage level, we observed significant differences in ED length of stay (urgent = 6.67 h, emergent = 5.97 h; p < 0.01). Hospital and intensive care unit admission rates were also significantly higher among emergent patients than among urgent patients (p < 0.05). There were 75 deaths (urgent = 32; emergent = 43), and the 30-day mortality rate was significantly higher among emergent patients (urgent = 8%, emergent = 15%; p < 0.05). The mESI level persisted as a significant factor associated with overall survival (hazard ratio = 1.7, 95% confidence interval = 1.09–2.81) in multivariable analysis. ConclusionThe mESI level is associated with ED disposition, ED length of stay, and overall survival in cancer patients presenting with COVID-19. These results indicate that the mESI triage tool can be effectively used in cancer patients with COVID-19, whose condition can rapidly deteriorate.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes.

While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED. We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major. Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n=442, 95.7%); lower acuity (Emergency Severity Index ≥3, n=426, 92.2%); due to persistence/progression of illness (n=403; 87.2%) with viral illness being the common diagnosis (n=159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these. APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

Emergency department length of stay and outcomes of emergency department-based intensive care unit patients.

ObjectiveEmergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED‐based intensive care units (ED‐ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED‐ICU on patient outcomes.MethodsWe retrospectively analyzed adult ED patients managed in the ED‐ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48‐hour mortality, and hospital mortality. Multivariable analyses’ covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3).ResultsWe included 5859 ED visits with subsequent care in the ED‐ICU. Median age, CCI, eSAPS3, ED LOS, and ED‐ICU LOS were 62 years (interquartile range [IQR], 48–73 years), 5 (IQR, 2–8), 46 (IQR, 36–56), 3.6 hours (IQR, 2.5–5.3 hours), and 8.5 hours (IQR, 5.3–13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = −3.4; 95% confidence interval [CI], −5.9 to −1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84–0.88), 48‐hour mortality (OR, 0.89; 95% CI, 0.82–0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85–0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88–0.93), but no associations with other outcomes.ConclusionsWe observed no significant associations between ED LOS before ED‐ICU transfer and worsened outcomes, suggesting an ED‐ICU may mitigate the risks of ED boarding of patients who are critically ill.

Creating a win-win for the health system and health Profession\u2019s education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department

BackgroundClinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration.MethodsAn interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked.ResultsClinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016–June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%).Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback.Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students.ConclusionsCreation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

The relationship between adverse childhood experiences, the frequency and acuity of emergency department utilization and primary care engagement

IntroductionA history of adverse child experiences (ACEs) is associated with increased high-risk adult behaviors, morbidity, mortality, and use of the emergency department. This study was designed to understand the relationship between ACEs and the characteristics of emergency department use and primary care engagement. MethodsAn in-person survey was conducted at an academic emergency department (ED) assessing ACE score, emergency department utilization and acuity, and primary care engagement. ResultsThe prevalence of ACEs was 71.1% with 1+ ACE and 32.5% with 4+ ACE. ACE scores of four or more were associated with three or more ED visits in the past year compared those with an ACE score of zero (OR 3.22; p < 0.05) and when adjusted for sociodemographic factors (OR 3.22; p < 0.10). Higher ACE scores were associated with lower acuity presentations as indicated by the Emergency Severity Index before (ACE score 1 OR 3.91 p < 0.05; ACE score 2–3 OR 2.35 p < 0.05; ACE score 4+ OR 3.95 p < 0.05) and after adjustment (ACE score 1 OR 3.80 p < 0.10; ACE 2–3 OR 3.50 p < 0.10; ACE 4+ OR 4.36 p < 0.05). There was no association between ACE score and having a primary care provider (PCP), frequency of PCP visits, or PCP rating. ConclusionHigher ACE scores were associated with higher emergency department utilization and lower acuity presentations but not associated with levels of primary care engagement. Additional investigations are needed to adequately characterize the discrete causal mechanisms behind these current findings.

Accuracy of Emergency Severity Index in older adults.

Background and importanceEmergency Severity Index is a five-level triage tool in the emergency department that predicts the need for emergency department resources and the degree of emergency. However, it is unknown whether this is valid in patients aged greater than or equal to 65 years.ObjectiveThe aim of the study was to compare the accuracy of the Emergency Severity Index triage system between emergency department patients aged 18–64 and greater than or equal to 65 years.Design, settings, and participantsThis was a retrospective observational cohort study of adults who presented to a Finnish emergency department between 1 February 2018 and 28 February 2018. All data were collected from electronic health records.Outcome measures and analysisThe primary outcome was 3-day mortality. The secondary outcomes were 30-day mortality, hospital admission, high dependency unit or ICU admission, and emergency department length of stay. The area under the receiver operating characteristic curve and cutoff performances were used to investigate significant associations between triage categories and outcomes. The results of the two age groups were compared.Main resultsThere were 3141 emergency department patients aged 18–64 years and 2370 patients aged greater than or equal to 65 years. The 3-day mortality area under the curve in patients aged greater than or equal to 65 years was greater than that in patients aged 18–64 years. The Emergency Severity Index was associated with high dependency unit/ICU admissions in both groups, with moderate sensitivity [18–64 years: 61.8% (50.9–71.9%); greater than or equal to 65 years: 73.3% (63.5–81.6%)] and high specificity [18–64 years: 93.0% (92.0–93.8%); greater than or equal to 65 years: 90.9% (90.0–92.1%)]. The sensitivity was high and specificity was low for 30-day mortality and hospital admission in both age groups. The emergency department length of stay was the longest in Emergency Severity Index category 3 for both age groups. There was no significant difference in accuracy between age groups for any outcome.ConclusionEmergency Severity Index performed well in predicting high dependency unit/ICU admission rates for both 18–64 years and greater than or equal to 65-year-old patients. It predicted the 3-day mortality for patients aged greater than or equal to 65 years with high accuracy. It was inaccurate in predicting 30-day mortality and hospital admission for both age groups.