Frequent Emergency Department Research Articles

Association between emergency department attendances, sociodemographic factors and long-term health conditions in the population of Norfolk and Waveney, England: Cross sectional study.

Demand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals' characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England. The study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual's sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models. 1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15-35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)). In the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.

Payment Innovation in Emergency Care: A Case for Global Clinician Budgets

The fee-for-service funding model for U.S. emergency department (ED) clinician groups is increasingly fragile. Traditional FFS payment systems offer no financial incentives to improve quality, address population health, or make value-based clinical decisions. FFS also does not support maintaining ED capacity to handle peak demand periods. In FFS, clinicians rely heavily on cross subsidization where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. While FFS survived decades of steady cuts in government reimbursement rates, it is increasingly strained due to visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups, combined with higher hospital boarding and clinical workloads are increasing workforce attrition. Here we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could effectively support robust clinician staffing over the long-term, ensure stability in clinical workload, and potentially improve the equity in payments. The model could also be combined with population health programs (e.g., pre- and post-ED telehealth, frequent ED use programs, and other innovations) which offer significant payer returns and address both quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation, as a precursor to broader adoption.

Emergency Department Use Among Combat and Non-Combat Post-9/11 Military Veterans.

Most post-9/11 Veterans have completed at least 1 combat deployment-a known factor associated with adverse health outcomes. Such Veterans are known to have unmet health care needs, and the emergency department (ED) may serve as a safety net, yet little is known about whether combat status is associated with more frequent ED use. We sought to evaluate the relationship between combat status and frequency of ED use among post-9/11 Veterans and assess the most common reasons for ED visits. This retrospective cohort study consisted of post-9/11 Veterans who enrolled in U.S. Department of Veterans Affairs (VA) care between fiscal years (FYs) 2005 and 2015. Data were obtained from the VA Corporate Data Warehouse. Incidence rates for ED visits for combat and non-combat Veterans were compared from FY 2010 to 2019 using zero-inflated negative binomial regression. The most frequent reasons for ED visits were determined using International Classification of Diseases codes. This study was approved by the Stanford Institutional Review Board. Among 1.3 million Veterans included in analyses, 70.4% had deployed to a combat zone. The mean (SD) age of our cohort was 32.6 (5.0) years and 83.5% of Veterans were male. After controlling for other factors, combat Veterans had 1.84 times the rate of ED visits compared to non-combat Veterans (95% CI, 1.83-1.85). Only combat Veterans had a mental health-related ED visit (suicidal ideations) among the top 3 reasons for ED presentation. Those who deployed to a combat zone had a significantly higher rate of ED use compared to those who did not. Further, mental health-related ED diagnoses appeared to be more prevalent in combat Veterans. These findings highlight the unique health care needs faced by combat Veterans and emphasize the importance of tailored interventions and support services for this specific population.

Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study.

Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

Comorbidity Burden and Health Care Utilization by Substance use Disorder Patterns among People with HIV in Florida.

Substance use disorder (SUD), a common comorbidity among people with HIV (PWH), adversely affects HIV clinical outcomes and HIV-related comorbidities. However, less is known about the incidence of different chronic conditions, changes in overall comorbidity burden, and health care utilization by SUD status and patterns among PWH in Florida, an area disproportionately affected by the HIV epidemic. We used electronic health records (EHR) from a large southeastern US consortium, the OneFlorida + clinical research data network. We identified a cohort of PWH with 3 + years of EHRs after the first visit with HIV diagnosis. International Classification of Diseases (ICD) codes were used to identify SUD and comorbidity conditions listed in the Charlson comorbidity index (CCI). A total of 42,271 PWH were included (mean age 44.5, 52% Black, 45% female). The prevalence SUD among PWH was 45.1%. Having a SUD diagnosis among PWH was associated with a higher incidence for most of the conditions listed on the CCI and faster increase in CCI score overtime (rate ratio = 1.45, 95%CI 1.42, 1.49). SUD in PWH was associated with a higher mean number of any care visits (21.7 vs. 14.8) and more frequent emergency department (ED, 3.5 vs. 2.0) and inpatient (8.5 vs. 24.5) visits compared to those without SUD. SUD among PWH was associated with a higher comorbidity burden and more frequent ED and inpatient visits than PWH without a diagnosis of SUD. The high SUD prevalence and comorbidity burden call for improved SUD screening, treatment, and integrated care among PWH.

A mapping review of interventions to address patients who frequently seek care in the emergency department

BackgroundThe high utilization of acute care services, particularly emergency departments (ED), continues to be a significant concern for healthcare providers. Numerous approaches have been studied to meet the care needs of patients who frequently seek care in the ED; however, there is no comprehensive review of the current literature base. As such, a current understanding of the interventions initiated within the ED to address the needs of frequent users is required. This mapping review had three objectives: identify the characteristics associated with the need to frequently seek care in the ED; identify interventions implemented to address the needs of this population; and identify gaps in the current evidence base.MethodsA knowledge map was created by scoping the literature to identify characteristics associated with frequent ED use and interventions implemented to address frequent use. Then, a literature search was conducted to determine what has been implemented by EDs to reduce frequent ED use. The literature was searched from 2013 to January 2023. MeSH terms and keywords were used to identify relevant studies. Studies implementing an intervention for those with characteristics associated with frequent ED use and reporting on ED use were included.ResultsTwenty-three (23) controlled trials and 35 observational studies were included. The most common populations were older adults, those with chronic conditions, and generic “frequent users”. No studies assessed Indigenous Peoples or racial minorities, and few assessed patients with a disability or patients experiencing homelessness. The most common interventions were referrals, care plans, case management, care coordination, and follow-up phone calls. Most studies reported ED revisits, hospitalization, costs, length-of-stay, or outpatient utilization. Few assessed patient or staff perspectives. About one-third of studies (n = 24) reported significant reductions in ED revisits.ConclusionsSimilar interventions, mainly focused on care coordination and planning, have been implemented to address frequent use of the ED. There are still significant gaps in the populations that have been studied. Efforts now must be undertaken to study more diverse populations whose care needs are not being met elsewhere and thus frequent the ED often.

Abstract 3468: Emerging lessons from patient-reported hospital discharge experiences among hospitalized cancer patients with frequent emergency department use

Abstract Background: While teamwork is essential to providing high-quality patient-centered care, challenges in interprofessional collaboration and decision-making in the hospital settings are common, especially for cancer patients. The purpose of this study was to identify emerging themes related to hospital discharge experiences among patients hospitalized for cancer who became frequent emergency department (ED) users following their hospital discharge. Design & Methods: A cohort of cancer patients discharged from an academic health center in Montreal (Canada) between October 2014 and November 2016 was assembled. Frequent ED (FED) users were identified as patients who had a > 4 ED visits in the year following hospital discharge using health administrative claims from the provincial universal health care program. Qualitative analysis of telephone interviews conducted with patients 30 days’ post-discharge were used for in-depth exploratory analyses to characterize hospital discharge experiences and transition process from the hospital to the community. Results: A cohort of 1253 cancer patients was formed. The mean age was 70.9 (SD=11.8) and the most frequent cancers included 488 (38.9%) respiratory and 309 (24.6%) upper digestive cancer. Overall, 14.5% (n=182) of patients became FED users. Content analyses revealed the most common emerging themes from the FED patients interviews on hospital discharge experiences. These included:1. Early hospital discharge putting patients at high risk of being re-admitted and going back to the ER shortly after that. Some patients mentioned post-discharge complications and emerging of new health issues that could have been avoided if patient was kept in the hospital for longer.2. Lack of communication between different specialists at the hospital. Some patients mentioned the help of a nurse as crucial during inpatient stays in maintaining communication between doctors. 3. Lack of communication of medications prescribed. Some patients mentioned the lack of communication of what doses was modified, what medications were stopped and which ones were newly prescribed.4. The need to schedule follow-up appointments at the time of hospital discharge. This becomes especially important for vulnerable patients who have been on pain medication during the hospital stay, affecting their cognitive abilities and making post-discharge planning more difficult. Conclusions: This study using integrated data from administrative claims and patient interviews provided insights into the challenges related to hospital discharge experiences and transition into community among hospitalized cancer patients with frequent emergency department use. Application of our findings could assist in hospital discharge preparation and improvement in healthcare delivery and health outcomes. Citation Format: Siyana Kurteva, Robyn Tamblyn. Emerging lessons from patient-reported hospital discharge experiences among hospitalized cancer patients with frequent emergency department use [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3468.

Health-Related Quality of Life of Omani Adult Patients with Sickle Cell Disease at the Sultan Qaboos University Hospital

Objectives: The quality of life of Omani adults with sickle cell disease (SCD) is not yet known. This study aimed to determine the health-related quality of life (HRQoL) of adult Omani patients with SCD attending a single tertiary center. Methods: A cross-sectional study was conducted among patients with SCD from June to October 2022 at the Sultan Qaboos University Hospital. A validated Arabic version of the 36-Item Short-Form Health Survey (SF-36) was used to assess HRQoL over eight domains. Results: A total of 235 patients with SCD participated in the study, of which the majority were female (74.9%) and 18–35 years of age (64.6%). The lowest HRQoL was reported for the domain of role limitations due to physical health (median score: 25.0; interquartile range [IQR]: 35.0), while the highest was seen for role limitations due to emotional problems (median score: 66.7, IQR: 100.0). Frequent SCD-related emergency department visits/hospital admissions and the adverse effect of SCD on patients’ social lives had a significant negative impact on SF-36 scores for all eight HRQoL domains (p ≤0.05). In addition, the impact of SCD on academic performance and a history of having been bullied due to SCD had a significant negative impact on SF-36 scores for several domains (p ≤0.05). Conclusion: Omani adult patients with SCD reported relatively poor HRQoL in several domains, with various factors found to have significant associations with poorer HRQoL. Healthcare providers and policy-makers should consider offering additional clinical, educational, and financial support to patients to enhance their HRQoL.
 Keywords: Sickle Cell Disease; Health-Related Quality of Life; Adults; Oman

Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews.

Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD. Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use. Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use. Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

Resource Use and Clinical Outcomes in Infants with Supraventricular Tachycardia Monitored with the Owlet Smart Sock

ObjectivesTo describe the prevalence of Owlet Smartsock (OSS) use in infants with supraventricular tachycardia (SVT), and associated demographic and clinical characteristics of users, and to analyze the association of OSS use on medical resource utilization and clinical outcomes from emergency department (ED) encounters for SVT. Study designSingle-center, retrospective cohort study of infants with confirmed SVT, from 2015 to 2022. OSS users and non-users were compared across clinical and demographic parameters. Medical resource utilization (phone calls, office visits, ED visits) and outcomes (need for intensive care, length of stay, echocardiographic function, clinical appearance) were compared between OSS users and non-users. ResultsOf 133 infants with SVT, OSS was used by 31/133 (23%), purchased prior to SVT diagnosis in 5/31 (16%) of users. No demographic difference was found between OSS users and non-users. OSS users had more phone notes than non-users, (p =0.002) and more ED visits, (p=0.03) but the number of office visits and medication adjustments did not differ. During ED presentation, OSS users had better preserved left ventricular ejection fraction on echocardiogram (p=0.04) and lower length of hospital stay by a mean 1.7 days (p=0.02). ConclusionOSS is used by a portion of infants with SVT. It is associated with more frequent phone calls and ED visits, but lower length of stay and better-preserved cardiac function upon presentation.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians.

To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs. We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence. We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup. Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

Emergency Department and Dental Clinic Perceptions of Appropriate, and Preventable, Use of the ED for Non-Traumatic Dental Conditions in Hot-Spot Counties: A Mixed Methods Study.

Frequency of emergency department (ED) use for nontraumatic dental conditions (NTDC) is a well-researched community health concern. However, research predominately relies on ambulatory ED discharge records. This explanatory sequential mixed methods study reviewed NTDC ED use in hot-spot counties and assessed perceptions around preventable and appropriate use among EDs and dental clinics. Tooth pain data (2015-2021) were drawn from State Medicaid, and the Early Notification of Community-Based Epidemics (ESSENCE). NTDC data were compiled using International Classification of Disease, Ninth and Tenth Revisions. Employing extreme case sampling, providers in counties with the highest per-capita NTDC ED use were interviewed. North Dakota experienced a decline in NTDC ED visits between 2017 and 2020, though the rate is now increasing. The greatest proportion of NTDC ED visits were among persons ages 20 to 34 and 35 to 44. ED and dental care staff have misconceptions around each other's roles in reducing NTDC ED visits, but unanimously suggest community-level prevention as a solution. NTDC ED use was perceived as "appropriate" care. However, there is consensus that improved access to, and utilization of, affordable and quality preventative dental care would reduce NTDC ED visits and improve overall community health, especially among populations experiencing greater inequities.

REPEAT AND SERIAL EMERGENCY DEPARTMENT (ED) OLDER ADULT USERS—A STATE-LEVEL ANALYSIS USING THE NYU-JHU ALGORITHM

Abstract Older adults account for 12-24% of all Emergency Department (ED) visits and studies have shown a 25-35% increase in older adult ED visits over time. While some studies have analyzed ED encounters over a single healthcare system, a year or a specific condition, research comparing the long-term frequent use of the ED across cohorts of older adults in the United States is limited. We address this gap by identifying characteristics associated with repeat (&amp;gt;1 visit during the time period) and serial/frequent (&amp;gt;=4/year) ED utilization for Maryland. Using the 2017-2019 State Emergency Department Databases (SEDD), we extracted ED visits among the elderly (&amp;gt;=60 years) population. By applying the modified New York University Algorithm by John Hopkins University (NYU-JHU-EDA), we classified ED visits into 11 categories, and we conducted bivariate and multivariate analyses to identify inter-age variations in the type of visits to the ED across single, repeat and serial users, after controlling for covariates. Of the total 5,331,843 ED visits between 2017 and 2019, 1,244,878 (~23%) were older adult visits. Relative to the 60–69-year-olds, those 80 and above had higher odds of being repeat users for emergent issues [OR=1.34, CI:1.07-1.67], primary-care treatable condition [OR=1.29, CI:1.03-1.62], and severe [1.30, CI: 1.03-1.64] and non-severe injuries [1.61, CI:1.28-2.01]. Relative to 60-69 year olds non-serial users, the oldest cohort demonstrated lower odds for psychiatric/alcohol and drug-related diagnoses [OR=0.63, CI:0.42, 0.95]. Our findings highlight the need to design age-group specific interventions to reduce the frequent ED utilization among the elderly in Maryland.

Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers.

This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction. The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction. Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis. Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills. Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.

Effects of Air Pollution on Respiratory Events and Pain Crises Among Children with Sickle Cell Disease in New York City

Introduction: Sickle cell disease (SCD) has the highest U.S. disease burden among Black and Hispanic populations, who more commonly live in urban areas with poor ambient air quality. The effect of air pollution exposure and social environmental factors on health outcomes in SCD have not been extensively studied, especially among children, and may further contribute to health disparities. Objectives: This study aims to examine the associations between air pollution exposure and acute respiratory and pain events and to determine whether neighborhood-level social disadvantage would modify their associations. Methods: We collected retrospective data on unscheduled outpatient visits, emergency department (ED) visits, and hospital admissions for respiratory events (i.e., respiratory tract infections, asthma exacerbation, acute chest syndrome) and vaso-occlusive pain crises requiring hospitalization (VOCs) for children with SCD in a tertiary care center in New York City (NYC) from 2015-2018. A total of 114 children with SCD (Table 1) were included in this study and had between 1-4 annual repeated measures of annual average air pollutants (i.e., black carbon (BC), fine particulate matter (PM 2.5), and nitrogen dioxide (NO 2)) with a total of 425 visits. Using home addresses, modeled data from the NYC Community Air Survey data were used to estimate street-level, annual average exposure to air pollution. The area deprivation index (ADI), a composite index of neighborhood-level social disadvantage, was dichotomized at the upper tertile (higher vs lower). Multivariable Poisson regression in generalized estimating equation (GEE) models were used to estimate relative risks (RR), after adjusting for potential covariates. Results: Overall, there were no significant associations between air pollution levels and acute respiratory and pain events among children with SCD. When stratified by ADI, increased exposure to PM 2.5 and NO 2, but not BC, was significantly associated with more frequent respiratory outpatient and ED visits among children residing in higher ADI neighborhoods (RR (95%CI)= 1.13 (1.00, 1.28) and 1.43 (1.01, 2.02) for PM 2.5 and NO 2, respectively, p&amp;lt;0.05 for all), but not among those in lower ADI neighborhoods (P-value for interaction=0.2 and 0.02 for PM 2.5 and NO 2, respectively) (Figure 1). Associations of air pollution with hospital admissions and VOCs were not observed for neither high ADI nor low ADI neighborhoods (p-value&amp;gt;0.05). Conclusions: Exposure to air pollutants increased respiratory complications among children living in deprived neighborhoods.

Outcomes of Vaso-Occlusive Episode Management in Adults Vs. Pediatrics in the Emergency Department

Introduction: Vaso-occlusive episodes (VOEs) contribute to significant morbidity and mortality in patients with sickle cell disease (SCD) and require timely treatment. Prompt intravenous fluids (IVF) and analgesics are key mainstays of care that may influence outcomes such as the increased disease burden from VOE-associated tissue infarction and the development of chronic pain. VOEs often lead to uncontrolled pain, requiring frequent ED (emergency department) visits and hospitalizations. Timely acute care management is crucial for curbing the significant polymerization of hemoglobin (Hgb) S and dehydration, which increases sickling of Hgb and can precipitate VOEs. In this study, we investigate the relationship between variables such as time to first IVF and IV pain medications in the ED for adult and pediatric patients with SCD presenting with VOEs and rates of admission. Methods: A retrospective study was conducted to analyze outcomes of adult and pediatric patients with SCD at Loma Linda University Medical Center ED and Children's Hospital ED. Patients with HgbSS, HgbSC, and HgbS/beta-thalassemia genotypes with at least two encounters at our institution for VOEs were included. Endpoints collected were time to first IVF in the ED, time to first IV pain medication, and rate of admission. Two-sample Wilcoxon rank-sum (Mann-Whitney) test was utilized to compare time to first IVF or pain medication in adult vs pediatric patients and the rates of admission. In these models, age, gender, and genotype were adjusted for. Results: 110 patients, 56 adult and 54 pediatric, with a total of 298 patient encounters were analyzed. In the adult population, 55% were male and 45% were female, with a median age of 30. In the pediatric population, 56% were male and 44% were female, with a median age of 10. Of the patients, 47 adult and 43 pediatric patients had severe genotypes (HgbSS or HgbS/beta-thalassemia). Compared to the adult population, the pediatric group had lower odds of receiving IVF and IV pain medications in &amp;lt; 90 minutes (min) of presentation to the ED (odds ratio (OR): 0.13, p=0.01 &amp; OR: 0.114, p=0.02, respectively), controlling for age, gender, and genotype. There was no significant difference in the median time to first IVF or IV pain medication in adults compared to pediatric patients (p=0.22 and p=0.42, respectively) (Table 1). When comparing adult and pediatric patients who received IVF and IV pain medications in &amp;lt; 90 min vs ≥ 90 min, the rates of admission were lower in the &amp;lt; 90 min groups (rates of admission by time to IVF: 56.9% for ≥ 90 min vs 51.8% for &amp;lt; 90 min in adults &amp; 62.4% for ≥ 90 min vs. 50.1% for &amp;lt; 90 min in pediatric patients; rates of admission by time to IV pain medications: 60.9% for ≥ 90 min vs 12.5% for &amp;lt; 90 min in adults &amp; 60.8% for ≥ 90 min vs 50.5% for &amp;lt; 90 min in pediatric patients) (Table 2). Conclusion: Overall, shorter time to IVF and IV pain medications in the ED led to decreased rates of admission for both adult and pediatric patients, regardless of age, gender, or genotype. Despite higher odds of adults receiving IVF and IV pain medications in &amp;lt; 90 min compared to pediatric patients, there was no difference in median time to IVF or IV pain medications. Thus, developing protocols to decrease the time to IVF and pain medications in the adult and pediatric ED setting may subsequently lead to improved outcomes for patients with SCD. The study calls for larger studies to further elucidate the significance of time to initial IVF and IV pain medications in the acute management of VOEs.

EGS P21 Hard to swallow, hard to treat

Abstract Background Deliberate foreign body ingestion (DFBI) presents unique medical, surgical, and ethical challenges. Often, patients with psychiatric conditions repeatedly ingest foreign bodies, leading to frequent emergency department visits. Standardised management guidelines are lacking, resulting in high hospitalisation rates, interventions, and complications. This study focuses on recent DFBI cases at our institution, providing insights into this complex condition and holistic management. Methods Patients admitted by the surgical team at Croydon University Hospital between 2017 and 2023 with DFBI were included. Data on demographics, clinical presentation, investigations, and management were collected. Complications, hospitalisations, interventions, and cost analysis were recorded. Results Eight patients presented a total of 52 times. The incidence of DFBI increased over time. Swallowed objects included knives, needles, magnets, glass, batteries, pencils, gloves, lighters, and screws. Each patient underwent an average of 21 X-rays, 2 CT scans, and 3 OGDs. Eleven laparotomies and 1 laparoscopy were performed. The average length of stay was 44.5 days. Complications included pulmonary embolism, pneumonia, enterotomy, hernia, and infection. The average cost per patient was £30,866.25. Conclusions DFBI poses a significant burden on healthcare systems. Patients face radiation exposure and repeated invasive interventions, necessitating a comprehensive approach. Understanding DFBI from a biopsychosocial and ethical perspective is crucial. A multidisciplinary team should be involved early, with clear goals. Further research is needed for optimal management pathways.

Epidemiology and outcomes of emergency department visits in systemic lupus erythematosus: Insights from the nationwide emergency department sample (NEDS).

Systemic lupus erythematosus (SLE) patients are prone to frequent emergency department (ED) visits. This study explores the epidemiology and outcomes of ED visits by patients with SLE utilizing the Nationwide Emergency Department Sample (NEDS). Using NEDS (2019), SLE ED visits identified using ICD-10 codes (M32. xx) were compared with non-SLE ED visits in terms of demographic and clinical features and primary diagnoses associated with the ED visits. Factors associated with inpatient admission were analyzed using logistic regression. Variations in ED visits by age and race were assessed. We identified 414,139 (0.35%) ED visits for adults ≥ 18years with SLE. ED visits with SLE comprised more women, Black patients, ages 31-50years, Medicare as the primary payer, and had higher comorbidity burden. A greater proportion of Black and Hispanic SLE patients who visited the ED were in the youngest age category of 18-30years (around 20%) compared to White patients (less than 10%). Non-White patients had higher Medicaid utilization (27%-32% vs 19% in White patients). Comorbidity patterns varied based on race, with more White patients having higher rates of hyperlipidemia and ischemic heart disease (IHD) and more Black patients having chronic kidney disease (CKD), hypertension, and heart failure. Categorizing by race, SLE/connective tissue disease (CTD) and infection were the most prevalent primary ED diagnosis in non-White and White patients, respectively. Age ≥ 65years, male sex, and comorbidities were linked to a higher risk of admission. Black race (OR 0.86, p = .01) and lowest income quartile (OR 0.78, p = .003) had lower odds of inpatient admission. Infection and SLE/CTD were among the top diagnoses associated with ED visits and inpatient admission. Despite comprising a significant proportion of SLE ED visits, Black patients had lower odds of admission. While the higher prevalence of older age groups, hyperlipidemia, and IHD among White patients may partly explain the disparate results, and further study is needed to understand the role of other factors including reliance on the ED for routine care compared among Black patients, differences in insurance coverage, and potential socioeconomic biases among healthcare providers.

Does ischaemia testing predict worse adverse outcomes in ANOCA patients?

Abstract Background Following the recent ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) it was revealed that the extent of ischaemia was not associated with an increased risk for adverse outcomes after adjustment for coronary artery disease (CAD) severity. How the extent of ischemia applies to outcomes for patients with stable angina without obstructive CAD is unknown. Purpose To determine if the presence of ischaemia impacted on 3-year clinical outcomes (mortality and readmission) in patients with Angina and Non-Obstructive Coronary Arteries (ANOCA). Methods ANOCA was defined as those presenting with chest pain symptoms consistent with angina and undergoing an elective angiogram. All consecutive ANOCA (stenosis &amp;lt;50%) enrolled in the CADOSA (Coronary Angiogram Database of South Australia) Registry between 2012-2018 were included. CADOSA captures all public hospital patients undergoing coronary angiography. Results Among 8,932 symptomatic patients undergoing elective angiography, 1,169 patients (60±11 years, 59% female) with ANOCA underwent ischaemic stress testing prior to angiography. Of these patients, 185 (16%) had no evidence of ischaemia (ANOCA ischaemia negative), and 984 (84%) had documented evidence of ischaemia (ANOCA ischaemia positive). The ANOCA ischaemic negative patients (relative to the ANOCA ischaemic positive patients) were (a) younger (58±11 vs 61±11, p&amp;lt;0.05), (b) in the year preceding diagnostic angiography, more often presented to the emergency department with chest pain (36% vs 21%, p&amp;lt;0.05) and required hospital admission (28% vs 14%, p&amp;lt;0.05), and (c) had more disabling angina, as assessed by the Canadian Cardiovascular Society Score (CCSS; CCSC-IV 19% vs 13%, p&amp;gt;0.05). At 3-year post-angiography follow-up, (i) cardiac mortality was similar (ANOCA negative 0% vs ANOCA positive 0.1%, p&amp;gt;0.05), but the ANOCA negative patients were more likely to present to the emergency department (26% vs 14%, p&amp;lt; 0.05) and require hospital readmission (18% vs 8%), compared to the ANOCA positive patients. Conclusion Patients with ANOCA and negative ischaemic testing have more disabling symptoms, with frequent emergency department presentations and readmissions, compared to those with a positive ischaemic test. Hence the presence of ischaemia on stress testing is not predictive of clinical outcomes and further investigation is required to identify predictors of outcomes in ANOCA.

Factors Affecting Treatment Compliance of Patients With COPD During the COVID-19 Pandemic

Objective: This study aimed to investigate the effects of difficulties experienced in the follow-up and treatment during the Coronavirus 2019 pandemic (COVID-19p), which included COVID-19 phobia and depression, on treatment compliance in patients with Chronic Obstructive Pulmonary Disease (COPD). Methods: This study included 123 patients with COPD. The COVID-19 Phobia Scale (C19P-S), Beck Depression Inventory (BDI), and Medication Adherence Report Scale (MARS) were used to assess the patients. Results: The mean age of patients with COPD was 64.56 ± 9.31 years. It was determined that our patients did not maintain regular outpatient follow-up mostly because of the fear of COVID-19 transmission (78.8%). Overall, 24% of our patients showed treatment noncompliance. A statistically significant relationship was found between COPD stages B and D and treatment compliance (p=0.01). Patients with frequent emergency department admissions (p = 0.01) and those with high BDI (p = 0.01) and C19P-S (p = 0.02) scores during the pandemic were found to have reduced treatment compliance. Conclusion: Patients with COPD with COVID-19 phobia, and depression had reduced treatment compliance. İt is necessary to be aware of these conditions and to plan appropriate interventions.