General Emergency Department Research Articles

Effectiveness of telemedicine in response to the COVID-19 pandemic.

The aim of this study was to evaluate the utility of the telemedicine care model implemented to treat and guide patients with COVID-19 related symptoms and indicators during the pandemic. This is a retrospective study with data collected from the electronic records of standardized forms for assistance. As a way of evaluating the work performed, the number of consultations, types of referrals, efficiency of care, and patient satisfaction were observed. Between April 2 and October 15, 2020, 92 professionals attended 3,660 patients by telemedicine; out of them, 523 (14.3%) were referred to a COVID-19 attending room, 128 (3.5%) to other specialties, 123 (3.4%) to a general emergency department, and 2,886 (78.9%) were monitored via home care. Of the total number of patients, 81 (2.2%) were hospitalized, and 13 (0.35%) died. Telemedicine offered useful tools for the care, treatment, and monitoring of patients with COVID-19 during the pandemic. The service was considered by most respondents as satisfactory, resolutive, or safe.

本邦のER型救急病院における救急車搬入患者のショックインデックスの有用性(Shock index as a predictor of inpatient mortality and hospital admission at the emergency department in Japan)

要旨【目的】ショックインデックス（shock index: SI）は救急患者の在院死亡の予測や入院予測に有用とされている。本邦においては救急車で来院した患者の在院死亡の予測や入院予測に来院時SIが有用であるか否かの報告はなく，これを検討した。【対象】2018年4月から2019年3月までに福岡徳洲会病院を救急車で受診した18歳以上の患者。主要評価項目を在院死亡，副次評価項目を入院の有無とした。心拍数または収縮期血圧に欠損が含まれる症例，明らかにバイタルサインの入力間違いと推察される症例は除外した。【結果】7,739名が解析対象となった。在院死亡は255名（3.3%），入院は2,679名（34.6%）であった。SI 1.1を超える患者は237名（3.1%）であった。SI 1.1を閾値としたときに在院死亡の陽性尤度比は6.88，入院の陽性尤度比は4.08であった。主病名が不整脈であった103名を除外したところ，SI 1.0以上の各閾値における入院の陽性尤度比はすべて5を超えていた。【結語】救急搬入患者の在院死亡の予測や入院予測において来院時SIが臨床的に有用であることが示唆された。SI>1.1は在院死亡の尤度上昇と関連しており，この閾値に該当する患者ではトリアージレベルを上げて対応することが望まれる。

Can the adverse childhood experiences (ACEs) checklist be utilized to predict emergency department visits among children and adolescents?

BackgroundExtensive literature has shown an association of Adverse Childhood Experiences (ACEs) with adverse health outcomes; however, its ability to predict events or stratify risks is less known. Individuals with mental illness and ACE exposure have been shown to visit emergency departments (ED) more often than those in the general population. This study thus examined the ability of the ACEs checklist to predict ED visits within the subsequent year among children and adolescents presenting to mental health clinics with pre-existing mental health issues.MethodsThe study analyzed linked data (n = 6100) from two databases provided by Alberta Health Services (AHS). The Regional Access and Intake System (RAIS 2016–2018) database provided data on the predictors (ACE items, age, sex, residence, mental health program type, and primary diagnosis) regarding children and adolescents (aged 0–17 years) accessing addiction and mental health services within Calgary Zone, and the National Ambulatory Care Reporting System (NACRS 2016–2019) database provided data on ED visits. A 25% random sample of the data was reserved for validation purposes. Two Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression models, each employing a different method to tune the shrinkage parameter lambda (namely cross-validated and adaptive) and performing 10-fold cross-validation for a set of 100 lambdas in each model were examined.ResultsThe adaptive LASSO model had a slightly better fit in the validation dataset than the cross-validated model; however, it still demonstrated poor discrimination (AUC 0.60, sensitivity 37.8%, PPV 49.6%) and poor calibration (over-triaged in low-risk and under-triaged in high-risk subgroups). The model’s poor performance was evident from an out-of-sample deviance ratio of − 0.044.ConclusionThe ACEs checklist did not perform well in predicting ED visits among children and adolescents with existing mental health concerns. The diverse causes of ED visits may have hindered accurate predictions, requiring more advanced statistical procedures. Future studies exploring other machine learning approaches and including a more extensive set of childhood adversities and other important predictors may produce better predictions. Furthermore, despite highly significant associations being observed, ACEs may not be deterministic in predicting health-related events at the individual level, such as general ED use.

A Scoping Review of Emergency Department Discharge Risk Stratification.

IntroductionAlthough emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge.MethodsWe conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified.ResultsPubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs.ConclusionNumerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients’ needs upon ED discharge.

Differences in radiation dose for computed tomography of the brain among pediatric patients at the emergency departments: an observational study

BackgroundComputed tomography (CT) is associated with a risk of cancer development. Strategies to reduce radiation doses vary between centers. We compared radiation doses of CT brain studies between pediatric and general emergency departments (EDs), and determine the proportion studies performed within the reference levels recommended by the International Commission on Radiological Protection (ICRP).MethodsA retrospective review was carried out in a healthcare network consisting of one pediatric ED and three general hospital EDs. Pediatric patients less than 16 years old with CT brain studies performed between 1 January 2015 and 31 December 2018 were included. Information on demographic, diagnosis, volume-averaged computed-tomography dose index and dose length product (DLP) were collected. Effective dose was then calculated from DLP using conversion factors, termed k-coefficients which were derived using a 16 cm head CT dose phantom.ResultsFour hundred and seventy-nine CT brain studies were performed – 379 (79.1%) at the pediatric ED. Seizure (149, 31.1%), head injury (147, 30.7%) and altered mental status (44, 9.2%) were the top three ED diagnoses. The median effective dose estimates were higher in general than pediatric EDs, particularly for those aged > 3 to ≤6 years old [1.57 mSv (IQR 1.42–1.79) versus 1.93 mSv (IQR 1.51–2.28), p = 0.047], > 6 to ≤10 years old [1.43 mSv (IQR 1.27–1.67) versus 1.94 mSv (IQR 1.61–2.59), p = 0.002) and > 10 years old (1.68 mSv (IQR 1.32–1.72) versus 2.03 mSv (IQR 1.58–2.88), p < 0.001). Overall, 233 (48.6%) and 13 (2.7%) studies were within the reference levels recommended by ICRP 60 and 103 respectively.ConclusionsRadiation doses for CT brain studies were significantly higher at general EDs and less than half of the studies were within the reference levels recommended by ICRP. The development of diagnostic reference levels (DRLs) as a benchmark and clinical justification for performing CT studies can help reduce the radiation risks in the pediatric population.

A prospective, multicenter evaluation of point-of-care ultrasound for appendicitis in the emergency department.

The main objective of this study was to evaluate the accuracy of point-of-care ultrasound (POCUS) for the diagnosis of appendicitis in a general emergency department (ED) population as performed by emergency physicians with variable ultrasound experience. We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential appendicitis presenting to the ED between July 2014 and February 2020. Each emergency physician-performed POCUS was interpreted at the bedside and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS and blinded expert interpretation compared to surgical pathology in patients undergoing appendectomy and advanced imaging in patients managed nonoperatively. A total of 256subjects were included in the primary analysis with an overall appendicitis prevalence of 28.1%. For the diagnosis of appendicitis, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.85 (95% confidence interval [CI]=0.74 to 0.92), 0.63 (95% CI=0.56 to 0.70), 2.29 (95% CI=1.85 to 2.84), and 0.24 (95% CI=0.14 to 0.42), respectively. Expert review yielded a lower sensitivity (0.74 [95% CI=0.62 to 0.83]) with a similar specificity (0.63 [95% CI=0.56 to 0.70]). POCUS is moderately accurate for acute appendicitis as performed by emergency physicians with a wide range of ultrasound expertise, but lacks adequate sensitivity and specificity to function as a definitive test in an undifferentiated ED population. Further study is warranted to elucidate the optimal role of integrated POCUS in the general approach to suspected appendicitis.

Improving Pediatric Readiness and Clinical Care in General Emergency Departments: A Multicenter Retrospective Cohort Study

To evaluate the impact of a collaborative initiative between general emergency departments (EDs) and the pediatric academic medical center on the process of clinical care in a group of general EDs. This retrospective cohort study assessed the process of clinical care delivered to critically ill children presenting to 3 general EDs. Our previous multifaceted intervention included the following components: postsimulation debriefing, designation of a pediatric champion, customized performance reports, pediatric resources toolkit, and ongoing interactions. Five pediatric emergency care physicians conducted chart reviews and scored encounters using the Pediatric Emergency Care Research Network's Quality of Care Implicit Review Instrument, which assigns scores between 5 and 35 across 5 domains. In addition, safety metrics were collected for medication, imaging, and laboratory orders. A total of 179 ED encounters were reviewed, including 103 preintervention and 76 postintervention encounters, with an improvement in mean total quality score from 23.30 (SD 5.1) to 24.80 (4.0). In the domain of physician initial treatment plan and initial orders, scores increased from a mean of 4.18 (0.13) to 4.61 (0.15). In the category of safety, administration of wrong medications decreased from 28.2% to 11.8% after the intervention. A multifaceted collaborative initiative involving simulation and enhanced pediatric readiness was associated with improvement in the processes of care in general EDs. This work provides evidence that innovative collaborations between academic medical centers and general EDs may serve as an effective strategy to improve pediatric care.

Do Patients with Acute Low Back Pain in Emergency Departments Have More Severe Symptoms than Those in General Practice? ASystematic Review with Meta-Analysis.

There is a common belief that patients presenting to emergency departments have more severe pain levels and functional limitations than those who are seen in general practice. The aim of this systematic review was to compare pain and disability levels of patients with acute low back pain presenting to general practice vs those presenting to emergency departments. Electronic searches were conducted in MEDLINE, EMBASE, and CINAHL from database inception to February 2019. Observational studies including patients with acute non-specific low back pain presenting to emergency departments and/or general practice were eligible. Pain and/or disability scores expressed on a 0-100 scale were the primary outcomes. Risk of bias was evaluated with a validated tool for observational studies, and the overall quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis with random effects and meta-regression were used to test for differences between the two settings. We included 12 records reporting results for 10 unique studies with a total of 6,999 participants from general practice (n = 6) and emergency departments (n = 4). There was low-quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher pain scores than those in general practice, with a mean difference of 17.3 points (95% confidence interval: 8.8 to 25.9 on a 0-100 scale). Similarly, there was low-quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher disability scores than those in general practice (mean difference: 21.7; 95% confidence interval: 4.6 to 38.7 on a 0-100 scale). Patients with acute non-specific low back pain presenting to emergency departments may report higher levels of pain and disability than those seen in general practice.

Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center

To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected. A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted. Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.

A QI Partnership to Decrease CT Use for Pediatric Appendicitis in the Community Hospital Setting.

Colleagues within a State Emergency Medical Service for Children (EMSC) community of practice formed the quality improvement team, representing multiple stakeholders across 3 independent institutions. The team generated project aims by reviewing baseline practice trends and implemented changes using the Model for Improvement. Ultrasound (US) use and nondiagnostic US rates served as process measures. Transfer and "over-transfer" rates served as balancing measures. Interventions included a GED pediatric appendicitis clinical pathway, US report templates, and case audit and feedback. Statistical process control tracked the main outcomes. Additionally, frontline GED providers shared perceptions of knowledge gains, practice changes, and teamwork. The 12-month baseline revealed a GED CT scan rate of 32%, a US rate of 63%, a nondiagnostic US rate of 77%, a transfer to a children's hospital rate of 23.5%, and an "over-transfer" rate of 0%. Project interventions achieved and sustained the primary aim by decreasing the CT scan rate to 4.5%. Frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. Engaging regional colleagues in a pediatric-specific quality improvement initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on the community of practice facilitated by Emergency Medical Service for Children may guide future improvement work in the state and beyond.

999Impact of Heatwaves on use of health services (GP and Emergency department visits)

Abstract Background Heatwaves are associated with increases in mortality and morbidity (mostly hospitalisations). However, evidence regarding heatwave impacts on the use of frontline health-services such as general practitioner (GP) consultations and emergency department (ED) services is limited. This study quantified the impact of heatwaves on the use of GP and ED services in Adelaide. Methods Data on GP services (2011-2016) from the Medicare Benefits Schedule and ED visits (2013-2018) were obtained from the Australian Bureau of Statistics and the Department of Health, respectively. Heatwaves were defined using Excess Heat Factor. Using time-stratified case-crossover models, we modelled heatwave-severity (low, severe/extreme) against the use of GP and ED services in the warm-season (October-March). Effect estimates are reported as relative risks (RRs). Results Total GP visits decreased during low-intensity heatwaves and increased during severe/extreme heatwaves (RR 1.14; 95%CI: 1.13-1.15). The highest increases during severe/extreme heatwaves were observed for respiratory (RR 1.36; 95%CI: 1.27-1.45) and psychiatric services. While ED visits decreased overall during low-intensity and severe/extreme heatwaves, those due to heat-light disorders (RR 4.23; 95%CI: 2.98-6.00), volume depletion, and respiratory diseases increased during severe/extreme heatwaves. Conclusions There were significant increases in the use of GP and specific ED services during heatwaves in Adelaide. Further research is needed to identify the intrinsic and extrinsic vulnerability factors contributing to these increases in Adelaide and other Australian cities. Key messages Impacts of heatwaves extend beyond mortality to include frontline health-services (GP/EDs) that are already challenged. Evidence presented may assist policymakers for resource allocation and healthcare workforce capacity building.

Resource Utilization During Low-Acuity Pediatric Emergency Department Visits.

The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs. We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs. There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01). More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.

Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department.

To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED). Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions. Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure. Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.

Predicting Unscheduled Emergency Department Return Visits Among Older Adults: Population-Based Retrospective Study.

BackgroundUnscheduled emergency department return visits (EDRVs) are key indicators for monitoring the quality of emergency medical care. A high return rate implies that the medical services provided by the emergency department (ED) failed to achieve the expected results of accurate diagnosis and effective treatment. Older adults are more susceptible to diseases and comorbidities than younger adults, and they exhibit unique and complex clinical characteristics that increase the difficulty of clinical diagnosis and treatment. Older adults also use more emergency medical resources than people in other age groups. Many studies have reviewed the causes of EDRVs among general ED patients; however, few have focused on older adults, although this is the age group with the highest rate of EDRVs.ObjectiveThis aim of this study is to establish a model for predicting unscheduled EDRVs within a 72-hour period among patients aged 65 years and older. In addition, we aim to investigate the effects of the influencing factors on their unscheduled EDRVs.MethodsWe used stratified and randomized data from Taiwan’s National Health Insurance Research Database and applied data mining techniques to construct a prediction model consisting of patient, disease, hospital, and physician characteristics. Records of ED visits by patients aged 65 years and older from 1996 to 2010 in the National Health Insurance Research Database were selected, and the final sample size was 49,252 records.ResultsThe decision tree of the prediction model achieved an acceptable overall accuracy of 76.80%. Economic status, chronic illness, and length of stay in the ED were the top three variables influencing unscheduled EDRVs. Those who stayed in the ED overnight or longer on their first visit were less likely to return. This study confirms the results of prior studies, which found that economically underprivileged older adults with chronic illness and comorbidities were more likely to return to the ED.ConclusionsMedical institutions can use our prediction model as a reference to improve medical management and clinical services by understanding the reasons for 72-hour unscheduled EDRVs in older adult patients. A possible solution is to create mechanisms that incorporate our prediction model and develop a support system with customized medical education for older patients and their family members before discharge. Meanwhile, a reasonably longer length of stay in the ED may help evaluate treatments and guide prognosis for older adult patients, and it may further reduce the rate of their unscheduled EDRVs.

Improving triage for children with comorbidity using the ED-PEWS: an observational study

ObjectiveTo assess the value of the Emergency Department–Pediatric Early Warning Score (ED-PEWS) for triage of children with comorbidity.DesignSecondary analysis of a prospective cohort.Setting and patients53 829 consecutive ED visits of...

The utility of telemedicine in pediatric emergency care: a scoping review.

The utility of telemedicine in pediatric emergency care: a scoping review. Owen Robinson, Shaelynn Zouboules, Hailey Lafave, Roger Galbraith, Eddy Lang Background: Widespread public health measures to combat COVID-19 and escalated parental fear in seeking medical care have compromised access to acute healthcare, leading clinicians to search for alternative methods of delivery. Pediatric emergency departments (ED) have seen significant reductions in documented visits without evidence of a reduction in needs. In Alberta, average daily visits to pediatric emergency and urgent care departments decreased 69.6%, from 952.2 in December 2019 to 289.6 in April 2020. While pediatric emergency telemedicine (PET) programs have the potential to alleviate said gaps in care, it is critical that these technologies are evaluated to ensure patient safety and efficacy. Implementation: This study aimed to serve as an implementation framework for future PET programs. A scoping review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-ScR). The primary objective was to map the existing literature and identify research gaps pertaining to the use of telemedicine in pediatric emergency departments. Primary areas of focus included direct-to-consumer (DTC) telemedicine, rural/regional applications, general ED utility, transfer of care and specialist consultation. This presentation focused on the aspects of DTC telemedicine, and its ability to potentially alleviate the present barriers to in-person presentations to EDs for acute pediatric health concerns. Our team consisted of two University of Calgary affiliated emergency physicians, three University of Calgary medical students, Canadian Agency for Drugs and Technology in Health research consultants, and a university librarian. Evaluation Methods: The outcomes of interest that we used to evaluate the relevant literature included: prevalence of PET; current applications; patient outcomes; patient satisfaction; provider satisfaction; and feasibility, challenges and barriers to implementation. In addition, we aimed to determine the proportion of literature focusing on DTC telemedicine, as this would be the desirable telemedicine application that could be used to supplement the gap in pediatric ED visits during the pandemic and mitigate the resulting health impacts. Lastly, we aimed to characterize both successes and challenges associated with DTC telemedicine in order to provide guidance for future research and policy. Results: Searches of the electronic databases returned 1617 studies. Following the two-step screening process, 37 studies met our inclusion criteria and six focused on DTC telemedicine. Study designs were all observational with all published in 2015 or later. The number of studies reporting data on the outcomes of interest were as follows: patient satisfaction (N=0); prevalence (N=1); provider satisfaction (N=1); patient outcomes (N=2); current applications (N=6); feasibility, challenges and barriers (N=6). Respiratory presentations were the most prevalent application. Three of six studies demonstrated agreement between telemedicine and in-person providers during acute assessments, demonstrating reliability of telemedicine. Conversely, two studies conveyed antimicrobial stewardship with conflicting results. Overall, results were largely positive with important challenges identified.Advice and Lessons Learned: Based on the lessons learned from our research, we recommend the following: 1) Implentation of a DTC telemedicine program can provide timely access to care, whileminimizing the health risks associated with visting the ED during the COVID-19 pandemic. 2) Respiratory complaints were among the most common presentations and thus we recommenddeveloping diagnostic and management algorithms to standardize the virtual care provided. 3) Continue quality improvement measures upon implementing a telemedicine program throughtimely feedback regarding physicians’ experiences and challenges in order to addressconcerns early and optimize efficacy of the program.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders

We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts. We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach. Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients. Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

The Impact of Dedicated Emergency and Admission Units on Infection and Death Risks in Hematological Patients Presented toa Tertiary Care Center

Introduction: Patients treated for hematological malignancies are susceptible to life-threatening complications, mainly infections. Prevention of infections and their related mortality presents a major ongoing challenge. The cost of dedicated inpatient services provides an incentive toward early discharge of hospitalized patients. In some high-risk cases (e.g., induction for acute leukemia), the common practice is to admit a patient for observation after completing chemotherapy. However, due to a shortage of dedicated facilities, such patients are often admitted to general internal wards. For ambulatory patients presenting with acute infection, pre-hospitalization emergency care is provided by either a dedicated hematological emergency service or general emergency department (ED). This study is aimed to assess effects of admission to specialized inpatient units versus general wards/ED on infection and death hazards in patients with hematological malignancies.Methods: This retrospective observational study analyzed data of all consecutive patients with hematological malignancies, treated at a large tertiary center between 01/2011-10/2015. We developed an algorithm allowing accurate identification of infectious events using electronic medical records. In addition to infection diagnosis codes, patient vital signs, and antibiotic prescriptions were included in the analysis to identify poorly recorded events. We assessed infection rates post chemotherapy and infection-related mortality in correlation with the hospital unit where the treatment was given.Results: The following outcomes were evaluated: hazard rates of infection within 30 days after completion of the treatment protocol and mortality from an infection. Of 8,786 patients that visited the hematology department, 2,330 received a total of 15,144 chemotherapy cycles within the study period. Excluded from the analysis were 523 cycles where an infection was diagnosed prior to or during chemotherapy administration as well as 2,205 cycles with significant missing data. Excluded were also 1,092 cycles prescribed during the first months after bone marrow transplantation, in which we couldn't differentiate between high-risk patients who received treatment for relapsed/refractory disease and low-risk ones receiving preplanned maintenance/consolidation therapy. The analysis included 11,324 therapeutic cycles given to 1,675 patients [mean age 58.2 years, 47% females, 328 (19.6%) acute leukemia, 119 (7.1%) chronic leukemia, 951 (56.8%) lymphoma, 280 (16.7%) multiple myeloma (MM)]; 88% of cycles were administered on an outpatient basis. Overall, 1,050 infectious events were identified within 30 days after chemotherapy. Patients admitted after chemotherapy conclusion for observation in a general ward had a significantly higher infection hazard rate than those admitted to the designated hematology unit (p-value <0.001) (fig 1). A total of 4,492 infectious episodes, were identified in 1,699 patients during the study period, including events occurring later than 30 days period following therapy. Patient mean age was 57.3 years, 43% were female, 539 (31.7%) had acute leukemia, 163 (9.6%) chronic leukemia, 697 (41%) lymphoma, 303 (17.8%) MM. The primary response to infection symptoms was given through the ED in 1,794 (40%) events. The mortality hazard rate was significantly higher in these patients than in those receiving emergency anti-infection treatment at the walk-in hematology outpatient unit [636 (14.2%), p-value <0.001] or in patients diagnosed with infections while hospitalized [1,131 (25.2%), p-value <0.001] (Fig 2). A patient-specific tool for calculating daily infection hazard risk after chemotherapy and infection-related mortality based on patient characteristics and location was created (available at: https://u0092023.shinyapps.io/InfectionHazards2/ and https://u0092023.shinyapps.io/Mortality/, respectively).Conclusions: In the current study, patients hospitalized for observation in a general ward had an increased infection hazard compared to those hospitalized in a designated hematology ward. Survival of patients, first treated for their infection at the walk-in hematology outpatient unit, was superior to that observed in patients treated in the ED and even to those who developed infection while being hospitalized for observation in general wards. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Use of health care services by people with substance use disorders in Belgium: a register-based cohort study

BackgroundThe objective of the study was to describe the frequencies of health-care utilization by people with substance use disorder (SUD), including contacts with general practitioners (GP), psychiatrists, emergency departments (ED) and hospital admissions and to compare this frequency to the general population.MethodsData from the national register of people who were in treatment for SUD between 2011 and 2014 was linked to health care data from the Belgian health insurance (N = 30,905). Four comparators were matched on age, sex and place of residence to each subject in treatment for SUD (N = 123,620). Cases were further divided in five mutually exclusive categories based on the main SUD (opiates, crack/cocaine, stimulants, cannabis and alcohol). We calculated the average number of contacts with GP, psychiatrists and ED, and hospital admissions per person over a ten year period (2008–2017), computed descriptive statistics for each of the SUD and used negative binomial regression models to compare cases and comparators.ResultsOver the ten-year period, people in treatment for SUD overall had on average 60 GP contacts, 3.9 psychiatrist contacts, 7.8 visits to the ED, and 16 hospital admissions. Rate ratios, comparing cases and corresponding comparators, showed that people in treatment for SUD had on average 1.9 more contacts with a GP (95 % CI 1.9-2.0), 7.4 more contacts with a psychiatrist (95 % CI 7.0-7.7), 4.2 more ED visits (95 % CI 4.2–4.3), and 6.4 more hospital admissions (95 % CI 6.3–6.5).ConclusionsThe use of health services for people with SUD is between almost two (GP) and seven times (psychiatrist) higher than for comparators. People in treatment for alcohol use disorders use health care services more frequently than people in treatment for other SUD. The use of health services remained stable in the five years before and after the moment people with SUD entered into treatment for SUD. The higher use of primary health care services by people with SUD might indicate that they have higher health care needs than comparators.

Development and validation of a scoring system for mortality prediction and application of standardized W statistics to assess the performance of emergency departments

BackgroundIn-hospital mortality and short-term mortality are indicators that are commonly used to evaluate the outcome of emergency department (ED) treatment. Although several scoring systems and machine learning-based approaches have been suggested to grade the severity of the condition of ED patients, methods for comparing severity-adjusted mortality in general ED patients between different systems have yet to be developed. The aim of the present study was to develop a scoring system to predict mortality in ED patients using data collected at the initial evaluation and to validate the usefulness of the scoring system for comparing severity-adjusted mortality between institutions with different severity distributions.MethodsThe study was based on the registry of the National Emergency Department Information System, which is maintained by the National Emergency Medical Center of the Republic of Korea. Data from 2016 were used to construct the prediction model, and data from 2017 were used for validation. Logistic regression was used to build the mortality prediction model. Receiver operating characteristic curves were used to evaluate the performance of the prediction model. We calculated the standardized W statistic and its 95% confidence intervals using the newly developed mortality prediction model.ResultsThe area under the receiver operating characteristic curve of the developed scoring system for the prediction of mortality was 0.883 (95% confidence interval [CI]: 0.882–0.884). The Ws score calculated from the 2016 dataset was 0.000 (95% CI: − 0.021 – 0.021). The Ws score calculated from the 2017 dataset was 0.049 (95% CI: 0.030–0.069).ConclusionsThe scoring system developed in the present study utilizing the parameters gathered in initial ED evaluations has acceptable performance for the prediction of in-hospital mortality. Standardized W statistics based on this scoring system can be used to compare the performance of an ED with the reference data or with the performance of other institutions.