Examining Emergency Department Research Articles

Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma.

The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients. We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups. A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks. This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.

Heat-Related Emergency Department Visits - United States, May-September 2023.

Unprecedented heat waves can affect all persons, but some are more sensitive to the effects of heat, including children and adults with underlying health conditions, pregnant women, and outdoor workers. Many regions of the United States experienced record-breaking high temperatures in 2023, with populations exposed to extremely high temperatures for prolonged periods. CDC examined emergency department (ED) visits associated with heat-related illness (HRI) from the National Syndromic Surveillance Program and compared daily HRI ED visit rates during the warm-season months (May-September) of 2023 with those during 2018-2022. In the 2023 warm-season months, daily HRI ED visit rates peaked in several regions and remained elevated for a prolonged duration. More males than females sought care in EDs for HRI, especially males aged 18-64 years. CDC issued multiple public health alerts using the Epidemic Information Exchange system to bring attention to increases in ED utilization for HRI. Deaths and illnesses associated with heat exposure are a continuing public health concern as climate change results in longer, hotter, and more frequent episodes of extreme heat. Near real-time monitoring of weather conditions and adverse health outcomes can guide public health practitioners' timing of risk communication and implementation of prevention measures associated with extreme heat.

Extreme heat impacts on acute care: Examining emergency department visits and hospital admissions during the 2021 British Columbia heatwave

IntroductionEmergency department (E.D.) visits and hospitalization patterns shifted dramatically during the 2021 extreme heat event (EHE) across the Greater Vancouver Area of southern British Columbia, Canada. MethodsIn this ecological timeseries study we analyze E.D. visits (n=36,432) and hospitalizations (n=18,624) between June 4th, 2021, and July 29th, 2021, using data from two administrative databases: (1) the Canadian National Ambulatory Care Reporting System; and (2) and the Canadian Discharge Abstract Database data. Using Mann-U Whitney tests, we compared how E.D. visits, hospitalizations, and patient diagnoses changed during a seven-day EHE and two subsequent lag periods compared to the surrounding baseline period. We also use a distributed lag non-linear model to analyze the relationship between daily maximum temperatures and daily E.D. visits during the study period. ResultsWe observed a statistically significant increase in overall E.D. visits during the EHE and during the week following the EHE, and a positive relationship between daily maximum temperature and relative risk of an E.D. visit. Further, there were significant increases in critically ill patients presenting to the E.D. during the EHE, based on Canadian Triage Acuity Scale (CTAS) and increases in key diagnoses, including acute kidney failure, heatstroke, and dehydration. ConclusionsHeatwaves have significant impacts on public health and acute care systems beyond heat-related deaths. Complications associated with heat exposure and surges in patient volume have implications for internal medicine, emergency medicine, and psychiatry departments. Better understanding the disease patterns associated with extreme heat events is essential to health system planning and response.

Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy

Polypharmacy is associated with mortality, falls, hospitalizations, and functional and cognitive decline. The study of polypharmacy-related interventions has increased substantially, prompting the need for an updated, more focused systematic overview. To systematically evaluate and summarize evidence across multiple systematic reviews (SRs) examining interventions addressing polypharmacy. A search was conducted of MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects for articles published from January 2017-October 2022, as well as those identified in a previous overview (January 2004-February 2017). Systematic reviews were included regardless of study design, setting, or outcome. The evidence was summarized by 4 categories: (1) medication-related process outcomes (eg, potentially inappropriate medication [PIM] and potential prescribing omission reductions), (2) clinical and functional outcomes, (3) health care use and economic outcomes, and (4) acceptability of the intervention. Fourteen SRs were identified (3 from the previous overview), 7 of which included meta-analyses, representing 179 unique published studies. Nine SRs examined medication-related process outcomes (low to very low evidence quality). Systematic reviews using pooled analyses found significant reductions in the number of PIMs, potential prescribing omissions, and total number of medications, and improvements in medication appropriateness. Twelve SRs examined clinical and functional outcomes (very low to moderate evidence quality). Five SRs examined mortality; all mortality meta-analyses were null, but studies with longer follow-up periods found greater reductions in mortality. Five SRs examined falls incidence; results were predominantly null save for a meta-analysis in which PIMs were discontinued. Of the 8 SRs examining quality of life, most (7) found predominantly null effects. Ten SRs examined hospitalizations and readmissions (very low to moderate evidence quality) and 4 examined emergency department visits (very low to low evidence quality). One SR found significant reductions in hospitalizations and readmissions among higher-intensity medication reviews with face-to-face patient components. Another meta-analysis found a null effect. Of the 7 SRs without meta-analyses for hospitalizations and readmissions, all had predominantly null results. Two of 4 SRs found reductions in emergency department visits. Two SRs examined acceptability (very low evidence quality), finding wide variation in the adoption of polypharmacy-related interventions. This updated systematic overview noted little evidence of an association between polypharmacy-related interventions and reduced important clinical and health care use outcomes. More evidence is needed regarding which interventions are most useful and which populations would benefit most.

Hospitalisations and emergency department presentations by older individuals accessing long-term aged care in Australia.

Objective The study examined emergency department (ED) presentations, unplanned hospitalisations and potentially preventable hospitalisations in older people receiving long-term care by type of care received (i.e. permanent residential aged care or home care packages in the community), in Australia in 2019. Methods A retrospective cohort study was conducted using the Registry of Senior Australians National Historical Cohort. Individuals were included if they resided in South Australia, Queensland, Victoria or New South Wales, received a home care package or permanent residential aged care in 2019 and were aged ≥65 years. The cumulative incidence of ED presentations, unplanned hospitalisations and potentially preventable hospitalisations in each of the long-term care service types were estimated during the year. Days in hospital per 1000 individuals were also calculated. Results The study included 203,278 individuals accessing permanent residential aged care (209,639 episodes) and 118,999 accessing home care packages in the community (127,893 episodes). A higher proportion of people accessing home care packages had an ED presentation (43.1% [95% confidence interval, 42.8-43.3], vs 37.8% [37.6-38.0]), unplanned hospitalisation (39.8% [39.6-40.1] vs 33.4% [33.2-33.6]) and potentially preventable hospitalisation (11.8% [11.6-12.0] vs 8.2% [8.1-8.4]) than people accessing permanent residential aged care. Individuals with home care packages had more days in hospital due to unplanned hospitalisations than those in residential care (7745 vs 3049 days/1000 individuals). Conclusions While a high proportion of older people in long-term care have ED presentations, unplanned hospitalisations and potentially preventable hospitalisations, people in the community with home care packages experience these events at a higher frequency.

Seasonal Trends in Emergency Department Visits for Mental and Behavioral Health Conditions Among Children and Adolescents Aged 5-17 Years - United States, January 2018-June 2023.

Mental and behavioral health conditions among school-aged children, including substance use disorders and overall emotional well-being, are a public health concern in the United States. Timely data on seasonal patterns in child and adolescent conditions can guide optimal timing of prevention and intervention strategies. CDC examined emergency department (ED) visit data from the National Syndromic Surveillance Program for 25 distinct conditions during January 2018-June 2023 among U.S. children and adolescents aged 5-17 years, stratified by age group. Each year, during 2018-2023, among persons aged 10-14 and 15-17 years, the number and proportion of weekly ED visits for eight conditions increased in the fall school semester and remained elevated throughout the spring semester; ED visits were up to twice as high during school semesters compared with the summer period. Among children aged 5-9 years, the number and proportion of visits increased for five mental and behavioral health conditions. Seasonal increases in ED visits for some conditions among school-aged children warrant enhanced awareness about mental distress symptoms and the challenges and stressors in the school environment. Systemic changes that prioritize protective factors (e.g., physical activity; nutrition; sleep; social, community, or faith-based support; and inclusive school and community environments) and incorporate preparedness for increases in conditions during back-to-school planning might improve child and adolescent mental health.

Cold-related injuries among patients experiencing homelessness in Toronto: a descriptive analysis of emergency department visits.

Homelessness increases the risk of cold-related injuries. We examined emergency department visits for cold-related injuries in Toronto over a 4-year period, comparing visits for patients identified as homeless to visits for patients not identified as homeless. This descriptive analysis of visits to emergency departments in Toronto between July 2018 and June 2022 used linked health administrative data. We measured emergency department visits with cold-related injury diagnoses among patients experiencing homelessness and those not identified as homeless. Rates were expressed as a number of visits for cold-related injury per 100,000 visits overall. Rate ratios were used to compare rates between homeless vs. not homeless groups. We identified 333 visits for cold-related injuries among patients experiencing homelessness and 1126 visits among non-homeless patients. In each of the 4years of observation, rate ratios ranged between 13.6 and 17.6 for cold-related injuries overall, 13.7 and 17.8 for hypothermia, and 10.3 and 18.3 for frostbite. Rates per 100,000 visits in the fourth year (July 2021 to June 2022) were significantly higher than in the pre-pandemic period. Male patients had higher rates, regardless of homelessness status; female patients experiencing homelessness had higher rate ratios than male patients experiencing homelessness. Patients experiencing homelessness visiting the emergency department are much more likely to be seen for cold-related injuries than non-homeless patients. Additional efforts are needed to prevent cold-related exposure and consequent injury among people experiencing homelessness.

Visits to Alberta Emergency Departments for Child Mental Health Concerns During the COVID-19 Pandemic: An Examination of Visit Trends in Relation to School Closures and Reopenings.

We examined emergency department (ED) mental health visit trends by children in relation to periods of school closure and reopening during the COVID-19 pandemic in Alberta, Canada. Mental health visits by school-aged children (5 to <18 years) were extracted from the Emergency Department Information System, a province-wide database, from March 11, 2020, to November 30, 2021 (pandemic period; n = 18,997) and March 1, 2019, to March 10, 2020 (1-year, prepandemic comparator period; n = 11,540). We calculated age-specific visit rates and compared rate differences between periods of school closure (March 15-June 30, 2020; November 30, 2020-January 10, 2021; April 22-June 30, 2021) and reopening (September 4-November 29, 2020; January 11-April 21, 2021; September 3-November 30, 2021) to matched prepandemic periods. We used a ratio of relative risk to examine the risk of a visit during closures versus reopenings. The cohort included 11,540 prepandemic visits and 18,997 pandemic visits. Compared with prepandemic periods, ED visit rates increased across all ages during the first (+85.53%; 95% confidence interval [CI], 73.68% to 100.41%) and third (+19.92%; 95% CI, 13.28% to 26.95%) school closures, and decreased during the second closure (-15.37%; 95% CI, -22.22% to -7.92%). During school reopenings, visit rates decreased across all ages during the first reopening (-9.30%; 95% CI, -13.94% to -4.41%) and increased during the third reopening (+13.59%; 95% CI, 8.13% to 19.34%); rates did not change significantly during the second reopening (2.54%; 95% CI, -3.45% to 8.90%). The risk of a visit during school closure versus reopening was only higher for the first closure with 2.06 times the risk (95% CI, 1.88 to 2.25). Emergency department mental health visit rates were highest during the first school closure of the COVID-19 pandemic, and the risk of a visit during this closure period was twice compared with when schools first reopened.

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans.

Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.

Emergency Department and Hospital Utilization Among Older Adults Before and After Identification of Elder Mistreatment

Elder mistreatment is common and has serious health consequences. Little is known, however, about patterns of health care utilization among older adults experiencing elder mistreatment. To examine emergency department (ED) and hospital utilization of older adults experiencing elder mistreatment in the period surrounding initial mistreatment identification compared with other older adults. This retrospective case-control study used Medicare insurance claims to examine older adults experiencing elder mistreatment initially identified between January 1, 2003, and December 31, 2012, and control participants matched on age, sex, race and ethnicity, and zip code. Statistical analysis was performed in April 2022. We used multiple measures of ED and hospital utilization patterns (eg, new and return visits, frequency, urgency, and hospitalizations) in the 12 months before and after mistreatment identification. Data were adjusted using US Centers for Medicare and Medicaid Services Hierarchical Condition Categories risk scores. Chi-squared tests and conditional logistic regression models were used for data analyses. This study included 114 case patients and 410 control participants. Their median age was 72 years (IQR, 68-78 years), and 340 (64.9%) were women. Race and ethnicity were reported as racial or ethnic minority (114 [21.8%]), White (408 [77.9%]), or unknown (2 [0.4%]). During the 24 months surrounding identification of elder mistreatment, older adults experiencing mistreatment were more likely to have had an ED visit (77 [67.5%] vs 179 [43.7%]; adjusted odds ratio [AOR], 2.95 [95% CI, 1.78-4.91]; P < .001) and a hospitalization (44 [38.6%] vs 108 [26.3%]; AOR, 1.90 [95% CI, 1.13-3.21]; P = .02) compared with other older adults. In addition, multiple ED visits, at least 1 ED visit for injury, visits to multiple EDs, high-frequency ED use, return ED visits within 7 days, ED visits for low-urgency issues, multiple hospitalizations, at least 1 hospitalization for injury, hospitalization at multiple hospitals, and hospitalization for ambulatory care sensitive conditions were substantially more likely for individuals experiencing elder mistreatment. The rate of ED and hospital utilization for older adults experiencing elder mistreatment was much higher in the 12 months after identification than before, leading to more pronounced differences between case patients and control participants in postidentification utilization. During the 12 months after identification of elder mistreatment, older adults experiencing mistreatment were particularly more likely to have had high-frequency ED use (12 [10.5%] vs 8 [2.0%]; AOR, 8.23 [95% CI, 2.56-26.49]; P < .001) and to have visited the ED for low-urgency issues (12 [10.5%] vs 8 [2.0%]; AOR, 7.33 [95% CI, 2.54-21.18]; P < .001). In this case-control study of health care utilization, older adults experiencing mistreatment used EDs and hospitals more frequently and with different patterns during the period surrounding mistreatment identification than other older adults. Additional research is needed to better characterize these patterns, which may be helpful in informing early identification, intervention, and prevention of elder mistreatment.

Behavioral Health, Nursing Home Workforce, And More

From the Editor-In-Chief Health AffairsVol. 42, No. 2: Behavioral Health, Nursing Home Workforce & More Behavioral Health, Nursing Home Workforce, And MoreAlan R. WeilPUBLISHED:February 2023Free Accesshttps://doi.org/10.1377/hlthaff.2023.00023AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSBehavioral health careNursing homesWorkforce issuesEmergency departmentsTelehealthHealth equityThe February issue of Health Affairs covers behavioral health, including mental health and substance use; the nursing home workforce; and health equity issues such as racial and ethnic disparities in ambulance transportation destinations and adverse birth outcomes.Behavioral HealthIn the midst of a mental health provider shortage, Lisa Rotenstein and coauthors find an almost 50 percent increase in the share of primary care physician visits that address a mental health concern, with growth from 10.7 percent of visits in 2006–07 to 15.9 percent in 2016 and 2018. Black patients and Hispanic patients are 40 percent less likely than White patients and non-Hispanic patients, respectively, to have a mental health concern addressed during a primary care visit.K. John McConnell and colleagues use newly available national Medicaid claims data from 2018 to examine emergency department (ED) visits for mental health conditions among Medicaid beneficiaries. They report substantial state-to-state variation “both in ED visits for mental health conditions and in outpatient mental health visits, with these measures positively correlated.”Lori Uscher-Pines and coauthors explore recent trends in the use of telemedicine to address opioid use disorder (OUD). More than three-quarters of clinicians treating OUD report the use of one or more digital equity strategies designed to address barriers patients may have to using telemedicine, with about one-third offering real-time technical assistance and more than 15 percent supplying patients with electronic devices if they do not have them.Brendan Saloner and coauthors investigate smoking rates among people involved in the criminal legal system—a group of people with relatively high rates of smoking and substance use disorder (SUD). Using data from the period 2010–19, the authors find that “overall smoking rates among people with SUD decreased by 9.4 percentage points…during the study period, but they remained effectively unchanged in the subgroup of people with SUD who had criminal legal involvement.”Nursing Home WorkforceUsing a novel database of real estate investment trust (REIT) investments in US nursing homes and Medicare cost data from the period 2013–19, Robert Tyler Braun and coauthors determine that REIT investment in a nursing home increased licensed practical nurse and certified nursing assistant staffing hours per resident day by 2.15 percent and 1.55 percent, respectively, while decreasing registered nurse staffing in years 2 and 3 after investment.Elizabeth White and coauthors explore the relationship between nursing home staff shift times and COVID-19 testing and vaccination status. They find that day-shift staff had the highest testing rates and odds of vaccination, whereas night-shift staff had the lowest.Adequate staffing is central to ensuring high nursing home quality. To help illuminate the implications of various policy recommendations, John Bowblis and coauthors analyze nursing home staff expenditures and determine that “any specific threshold for nursing staff expenditures…would have a varying degree of effectiveness in ensuring that any given nursing home was adequately staffed.” Ultimately, the authors argue, increased expenditures on staff do not necessarily translate to an increase in staffing levels.EquityChristine Pack and coauthors investigate ambulance destinations for patients transported in 2020 from the same ZIP code and find meaningful differences by race and ethnicity. “In half of the studied ZIP codes, at least 8 percent of White patients would have had to be transported to different hospitals to achieve evenness in the transport destinations of White and non-White patients,” the authors report.Clare Brown and coauthors examine disparities in rates of preterm birth and low birthweight across racial and ethnic subcategories. They find sizable variation in adverse birth outcomes within racial and ethnic groups, demonstrating that broad racial and ethnic categorizations can conceal important intragroup differences.Eunhae Grace Oh and coauthors analyze dialysis facility networks for Medicare Advantage (MA) plans in 2020, one year before changes that significantly increased MA enrollment among patients with end-stage renal disease (ESRD). Nearly one-quarter of dialysis networks were narrow, which the authors define as including 25 percent or less of the dialysis facilities within the plan’s service area. Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native beneficiaries with ESRD were more likely than White beneficiaries to be enrolled in narrow-network MA plans.Examining COVID-19 booster rates at the end of the first Omicron wave in 462 Massachusetts communities, Adam Gaffney and coauthors find lower rates in communities with higher uninsurance rates and lower prevalence of medical checkups, after controlling for demographic factors. They call for “innovative vaccination outreach efforts to communities with a high prevalence of chronic illness…to mitigate the inequitable burden of COVID-19.” Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 February 2023 Information© 2023 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

Client characteristics and service utilization with emergency department peer recovery specialists in a statewide opioid overdose prevention intervention

ABSTRACT Opioid peer recovery service programs are important interventions to increase treatment engagement, adherence, and completion among clients. Little research has examined emergency department (ED) peer recovery programs, the utilization of these services, and patient characteristics. This study examined client data (N = 1690; Mean age = 36.05 ± 12.04) from New Jersey’s Opioid Overdose Recovery Program (OORP). Between group analyses examined differences between repeated OORP service utilization and those new to OORP services on patient characteristics, primary substance of use, and mental health diagnosis. Exploratory logistic regression analyses were conducted to examine clinically relevant variables as predictors of repeated OORP service utilization. Sociodemographic differences were observed among those with repeated OORP service utilization, including a higher number of prior overdoses (3.87 ± 4.78) and a greater proportion to use heroin (93.34%). Multivariate logistic regression analyses showed several clinically important indicators associated with repeated OORP service utilization. Findings showed that several notable sociodemographic and clinical indicators associated with multiple OORP service utilization that can help support future prevention and clinic-intervention programs. These findings provide important information on participants at high risk for fatal overdose, and considerations for measured intervention services.

Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group.

IntroductionHealth equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex‐based differences, including metrics such as door‐to‐room (DTR) and door‐to‐healthcare practitioner (DTP) times to look for potential signs of systemic bias.MethodsWe conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min.ResultsA total of 106,011 adult visits to the ED were investigated. Female patients had 8‐min longer median length‐of‐stay (LOS) than males (P < 0.01). Females had longer DTR (2‐min median difference, P < 0.01), and longer DTP (5‐min median difference, P < 0.01). Females had longer median door‐to‐over‐the‐counter analgesia time (84 vs. 80, P = 0.58), door‐to‐advanced analgesia (95 vs. 84, P < 0.01), door‐to‐PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door‐to‐intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males.ConclusionNumerous statistically significant differences were identified in throughput and care measures—mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.

Toxic Exposures Among Young Children One Year into the COVID-19 Pandemic: A Retrospective Review of Three San Francisco Bay Area Emergency Departments

BackgroundDaycare and school closures prompted by shelter-in-place orders may have increased opportunities for unintentional ingestions among young children. ObjectivesWe examined emergency department (ED) presentations for toxic exposures among young children during the COVID-19 pandemic in the San Francisco Bay Area, which had some of the strictest and most prolonged shelter-in-place policies in the United States. MethodsWe performed a retrospective cross-sectional study of children 0 to 5 years of age who presented with an ED International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of toxic exposure within a tertiary care hospital system between March 16, 2016 and March 15, 2021. We considered the period after March 16, 2020 to represent the pandemic. ResultsDuring the pandemic, the absolute number of poisonings among young children remained stable. Overall, ED encounters within this cohort decreased by 55%, which doubled the relative toxic exposure rate per 1000 ED encounters from 4.99 (95% confidence interval [CI] 3.19–5.90) to 9.79 (95% CI 8.09–11.49). Rates of admission, severe medical complications, operating room case requests, and length of stay were not significantly different. Shelter-in-place was associated with significantly higher odds of cannabis ingestion (odds ratio = 2.70, 95% CI 1.60–4.49). ConclusionDespite dramatic decreases in overall ED patient volumes, the absolute number and severity of toxic exposures were similar during the pandemic compared with previous years. © 2022 Elsevier Inc.

High sensitivity troponin - Six hours is the magic number

BackgroundHigh sensitivity troponin assays have become widespread for emergency department evaluation of acute chest pain. We assessed if a high sensitivity troponin under the 99th percentile upper reference limit drawn at 6 h or greater from symptom onset could safely rule out acute coronary syndrome in patients who did not meet the rapid rule-out strategy. MethodsWe conducted a multicenter retrospective study examining emergency department patients with chest pain who did not meet rapid-rule out criteria and were admitted for further evaluation. Among these admitted patients, we assessed the rate of clinically relevant adverse cardiac events (death, cardiac or respiratory arrest, STEMI, or life-threatening arrhythmia) and NSTEMI in patients with high sensitivity troponin less than the 99th percentile value obtained after at least 6 h of chest pain. ResultsOut of 1187 patients admitted, we found 30 clinically relevant adverse cardiac events, all of which occurred in patients admitted for another compelling reason or ischemic ECG. 36 patients had an NSTEMI, of which 33 were identified with high sensitivity troponin greater than 99th percentile upper reference limit within 6 h of chest pain onset. This left 0 clinically relevant adverse cardiac events and 3 NSTEMI among the 429 patients with high sensitivity troponin less than the 99th percentile at 6 h and nonischemic ECG and no other compelling reason for admission. ConclusionThis study assessed patients with chest pain with high sensitivity troponin values between 3 ng/L and the 99th percentile upper reference limit after 6 h of chest pain and found that they have a low rate of clinically relevant adverse cardiac events and NSTEMI.

The responsibility to care: lessons learned from emergency department workers' perspectives during the first wave of the COVID-19 pandemic in Canada.

BackgroundThis study’s objective was to examine emergency department (ED) workers’ perspectives during the Canadian COVID-19 first wave.MethodsThis qualitative study included workers from nine Canadian EDs who participated in 3 monthly video focus groups between April and July 2020 to explore (1) personal/professional experiences, (2) patient care and ED work, (3) relationships with teams, institutions and governing bodies. Framework analysis informed data collection and analysis.ResultsThirty-six focus groups and 15 interviews were conducted with 53 participants (including 24 physicians, 16 nurses). Median age was 37.5 years, 51% were female, 79% had more than 5 years’ experience. Three main themes emerged. (1) Early in this pandemic, participants felt a responsibility to provide care to patients and solidarity toward their ED colleagues and team, while balancing many risks with their personal protection. (2) ED teams wanted to be engaged in decision-making, based on the best available scientific knowledge. Institutional decisions and clinical guidelines needed to be adapted to the specificity of each ED environment. (3) Working during the pandemic created new sources of moral distress and fatigue, including difficult clinical practices, distance with patients and families, frequent changes in information and added sources of fatigue. Although participants quickly adapted to a “new normal”, they were concerned about long-term burnout. Participants who experienced high numbers of patient deaths felt especially unprepared.InterpretationED workers believe they have a responsibility to provide care through a pandemic. Trust in leadership is supported by managers who are present and responsive, transparent in their communication, and involve ED staff in the development and practice of policies and procedures. Such practices will help protect from burnout and ensure the workforce’s long-term sustainability.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43678-022-00306-z.

Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study.

Background:The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups.Methods:This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health–related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale.Results:The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: “short duration” (frequent, regularly spaced visits), “older patients” (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), “young mental health” (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health–related and alcohol-related visits) and “injury” (increased prevalence of injury-related visits).Interpretation:From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.

Healthcare service use patterns among autistic adults: A systematic review with narrative synthesis.

Autistic adults often have complex healthcare needs due to factors like having other health conditions, sensory sensitivities, and limited access to healthcare providers who are trained to provide care for them. All these factors may influence the healthcare services that autistic adults use. In this review, we searched six electronic research databases to gather the most recent evidence about how often autistic adults use five important healthcare services (the emergency department, hospitalization, outpatient mental health, preventive services, and primary care) compared to populations of non-autistic adults. A total of 16 articles were ultimately included in this review. Most articles found that autistic adults had equal or higher use of healthcare services than non-autistic adults. Autistic adults frequently used the emergency department and hospital. This may indicate that routine outpatient care in the community is not meeting their needs. Our findings show the importance of improving care at this level for autistic adults to reduce overuse of the emergency department (in this article referred to as ED) and hospital.

Abstract 12261: Access to Care among Hispanic Patients Hospitalized for Lower Extremity Peripheral Artery Disease

Introduction: Compared to other racial/ethnic groups, Hispanics are less likely to access regular primary care, which can delay detection and management of PAD. It is unknown whether in admissions for PAD, a trend towards more burden is observed for Hispanic vs. non-Hispanic White (NHW) patients. We therefore examined emergency department (ED) and elective admissions, length of stay (LOS), and costs accrued by ethnicity in patients hospitalized for primary PAD. Methods: The 2011-2017 National Inpatient Sample data were used to identify admissions in Hispanics and NHWs and whether the patient sought care via the ED and if the admission was elective. Yearly and overall percentages for each were determined, and temporal trends evaluated with the Cochran-Mantel-Haenszel test, stratified by ethnicity. Differences in median LOS and cost by ethnicity were evaluated with the Wilcoxon rank sum test. Results: From 2011-2017, there were 1,018,220 PAD hospitalizations (39% female, 14% Hispanic) and the percentage of patients who accessed inpatient care via the ED increased in Hispanics and NHWs, but was consistently higher in Hispanics (Fig. 1, all P trend &lt;0.0001). Across all years, 58.0% (82,047 of 141,551) of admissions in Hispanics were via the ED compared to 36.7% (321,932 of 876,669) in NHWs ( d =0.48) and elective admissions were higher in NHWs (396,294; 45.2%) than in Hispanics (38,661; 27.3%, d =0.43). Median LOS (4.5 vs. 3.7 days) and cost ($63,813 vs. $52,368) were higher in Hispanics than NHWs ( p &lt;.0001). Conclusions: Hispanic patients are more likely than NHWs to seek emergent, non-elective inpatient PAD care and to be admitted for longer and accrue greater costs. They are also increasingly more likely to access this care via the ED which may provide fewer barriers than other settings, especially for uninsured patients or those without legal immigration status. More accessible outpatient care may potentially reduce ED burden and improve PAD management for this population.

Powerless in the Virgin Islands: Emergency Department and Wound Care Clinic Utilization Following the 2017 Hurricanes Irma and Maria on St. Thomas, U.S. Virgin Islands.

The main objective of this work was to characterize the prevalence of acute medical needs by examining emergency department (ED) and outpatient wound care clinic (WCC) visits before, during, and after the 2017 Hurricanes Irma and Maria, in St. Thomas, United States (U.S.) Virgin Islands. Descriptive statistics and logistic regression were used to assess associations between the occurrence of the storms and visits due to injuries and chronic conditions presented to the ED and WCC from September 1, 2016 to May 31, 2018. ED visits increased and the rate of injury care was higher during the storms (12 patient visits per day) than before or after the storms (9 patient visits per day). WCC visits increased during (12%) and after the storms (45%), and were associated with patients 60 years and older. The odds of ED and WCC visits due to injury during the storms were significantly higher (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.17, 1.40) than prior to the storms. The odds for visits due to injuries were 1.19 (95% CI: 1.12, 1.28) times higher after the storms. Increases occurred in ED and WCC visits for injury care during the storms and in WCC visits after the storms. Public health preparedness mandates understanding how major hurricanes impact the prevalence of acute medical needs, and the factors that influence decisions to seek medical care, in their wake.