General Emergency Department Population Research Articles

Severe hyperlactatemia in the emergency department: clinical characteristics, etiology and mortality

BackgroundSevere hyperlactatemia (lactate level ≥ 10 mmol/L) is associated with high mortality rates in critically ill patients. However, there is limited data on emergency department (ED) patients. We aimed to investigate the clinical characteristics, etiology and outcomes of patients with severe hyperlactatemia in the ED setting.MethodsA retrospective cohort study was conducted at a tertiary care hospital in Thailand. We included adult patients with a venous lactate sample taken in the ED within one hour. We excluded patients after out-of-hospital cardiac arrest, transferred to/from another hospital or those with missing clinical data. Mortality rates were evaluated among patients with increasing degrees of lactate elevation and among patients with severe hyperlactatemia, stratified by causative etiology.ResultsWe analyzed venous lactate levels in 40,047 patients, with 26,680 included in the analysis. Among these, 1.7% had severe hyperlactatemia (lactate ≥ 10 mmol/L), 10.5% moderate (4–9.99 mmol/L), 28.8% mild (2—3.99 mmol/L), and 59.0% normal levels (< 2 mmol/L). Severe hyperlactatemia was associated with high mortality rates of 29%, 37%, and 38% at 7, 28, and 60 days respectively, significant ICU admissions and mechanical ventilation rates. Patients with severe hyperlactatemia were stratified into high (> 50% mortality), moderate (21–50%), and low (< 20%) 28-day mortality risk groups. High-risk conditions included non-septic shock, traumatic injuries/burns, and neurological issues, with mortality rates of 51.1%, 61.8%, and 57.1%, respectively. In the moderate risk group, namely infection without shock showed a high prevalence, with a mortality rate of 36%. In the low-risk group, seizures and fainting were associated with lower mortality, exhibiting mortality rates of 0%.ConclusionsSevere hyperlactatemia is associated with higher rates of ICU admission and mortality compared to other degrees of lactate elevation in a general ED population. However, mortality rates can vary considerably, depending on the underlying etiology associated with different primary diagnoses.

Drug-related emergency department visits: external validation of an assessment tool in a general emergency department population.

The process of identifying drug-related hospitalisations is subjective and time-consuming. Assessment tool for identifying hospital admissions related to medications (AT-HARM10) was developed to simplify and objectify this process. AT-HARM10 has not previously been externally validated, thus the predictive precision of the tool is uncertain. To externally validate AT-HARM10 in adult patients admitted to the emergency department (ED). This retrospective cross-sectional study investigated 402 patients admitted to the ED, Diakonhjemmet Hospital, Oslo, Norway. A trained 5th-year pharmacy student used AT-HARM10 to assess all patients and to classify their ED visits as possibly or unlikely drug-related. Assessment of the same patients by an interdisciplinary expert panel acted as the gold standard. The external validation was conducted by comparing AT-HARM10 classifications with the gold standard. According to AT-HARM10 assessments, 169 (42%) patients had a possible drug-related ED visit. Calculated sensitivity and specificity values were 95% and 71%, respectively. Further, positive and negative predictive values were 46% and 98%, respectively. Adverse effects/over-treatment and suboptimal treatment were the issues most frequently overestimated by AT-HARM10 compared with the gold standard. AT-HARM10 identifies drug-related ED visits with high sensitivity. However, the low positive predictive value indicates that further review of ED visits classified as possible drug-related by AT-HARM10 is necessary. AT-HARM10 can serve as a useful first-step screening that efficiently identifies unlikely drug-related ED visits, thus only a smaller proportion of the patients need to be reviewed by an interdisciplinary expert panel.

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population.

Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Assessment of outpatient chemotherapy and unplanned emergency department visits in a large community hospital system.

e18768 Background: Unplanned complications of outpatient chemotherapy can significantly affect patient oncologic outcomes, health, and increase cost of care. CMS rule OP-35 evaluates quality of care for Medicare patients by assessing the risk of emergency department (ED) visit within 30 days after outpatient chemotherapy administration. This study reviews this measure for all oncology patients treated in our community hospital setting. Methods: Patients treated between 02/2012 and 04/2021 were identified. Age at first chemotherapy administration, gender, cancer diagnosis, and chemotherapy regiment were evaluated. Chemotherapy was stratified into cytotoxic therapy, immunotherapy, targeted therapy, and endocrine therapy. ED visits were only those in our hospital system. 30-day risk of ED visit was calculated for individual chemotherapy administrations. Internal results were compared with our CMS OP-35 results for concordance. Results: There were 19,732 patients who received chemotherapy treatments between 02/2012 and 04/2021, with 262,379 chemotherapy administrations. Individual chemotherapy administration had 5.2% risk of a 30 day ED visit. Cumulative risk of a patient having a 30 day ED visit was 32.9%. From ED, patients had 61.2% rate of hospital admission, vs 24.8% rate for general ED population. By age at first chemotherapy administration, the risk of 30 day ED visit was 6.3% for age &lt; 18, 5.4% for age 18-64, and 5.9% for age &gt; = 65. Our rate was relatively stable between 2014 and 2020. Our corresponding CMS score was 5.5% in 2016, 5.5% in 2018, and 5.1% in 2019. By gender, the risk was 5.6% for male and 5.0% for female patients. By chemotherapy category, the risk was 5.9% for cytotoxic chemotherapy, 7.5% for immunotherapy, 4.2% for targeted therapy, and 5.2% for endocrine therapy. Carboplatin/paclitaxel was the most common drug combination administered, with 8.7% risk. Cytarabine/methotrexate combination had the highest risk at 57.0%. By ICD diagnosis, breast cancer accounted for most patients and most chemotherapy administrations, with 30 day ED visit risk of 3.6%. Multiple myeloma had the highest rate of chemotherapy administrations at 26.3 per patient and a risk of 4.0%, compared with 13.3 across the entire population. Stomach cancer had the highest risk of 30 day ED visit at 10.0%. Conclusions: The risk of 30 day unplanned ED visit was elevated in pediatric patients, and was similar in patients 18-64 and &gt; = 65 years of age, and corresponded well to our CMS OP-35 metric, despite only tracking internal ED visits. Immunotherapy had significantly elevated risk compared with cytotoxic therapy, while targeted therapy had the lowest risk of ED visit. There were significant differences depending on disease site. We have established a baseline, and developed a live dashboard in our electronic medical record to monitor this metric globally, and to intervene in patients at high risk of 30 day ED visit.

Screening for hazardous alcohol use in the Emergency Department: Comparison of phosphatidylethanol with the Alcohol Use Disorders Identification Test and the TimelineFollow-back.

Up to 15% of all visits to the Emergency Department (ED) are alcohol related. Identification of problematic alcohol use is important in this setting because it allows for intervention and prevention efforts. This study investigated the correlation between the objective phosphatidylethanol (PEth) marker and the subjective Alcohol Use Disorders Identification Test (AUDIT) and Timeline Followback Questionnaire (TLFB) as screening methods for hazardous alcohol use in the general ED population. This prospective cohort study included 301 ED patients (57% male) who were seen in the ED and required to give a blood sample. The correlation between the values of PEth (PEth 16:0/18:1 and PEth 16:0/18:2) and the scores on the AUDIT and TLFB were analyzed using Spearman's rank correlation coefficient. Differences between risk categories of PEth and AUDIT were also examined. The Spearman correlation coefficients between PEth 16:0/18:1|PEth 16:0/18:2 values and the AUDIT scores were moderate (PEth 16:0/18:1: 0.67, p < 0.001; PEth 16:0/18:2: 0.67, p < 0.001). Of the patients who scored 'low risk drinking/abstinence' according to the AUDIT questionnaire, respectively 1% and 4% had PEth 16:0/18:1|PEth 16:0/18:2 values indicating excessive alcohol use, and another 10% and 12% had PEth 16:0/18:1|PEth 16:0/18:2 values indicating moderate alcohol consumption. Of the 12 (PEth 16:0/18:1) and 25 (PEth 16:0/18:2) patients with high-risk values, respectively 25% and 40% scored in the lowest risk category on the AUDIT questionnaire. Spearman correlation coefficients between PEth 16:0/18:1|PEth 16:0/18:2 values and TLFB two-week scores were high (PEth 16:0/18:1: 0.74, p < 0.001; PEth 16:0/18:2: 0.82, p < 0.001). AUDIT scores were moderately correlated with PEth values in the general ED population. In almost all cases where there was not a good correlation, patients had high PEth values with low AUDIT scores. We conclude that PEth identifies patients with problematic alcohol use who are missed by the AUDIT questionnaire and therefore PEth could be used as an additional screening method for hazardous alcohol use in this population.

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.

Return Hospital Admissions Among 1419 COVID-19 Patients Discharged from Five U.S. Emergency Departments.

Although many ED patients with known or suspected Covid-19 require hospital admission, the majority are discharged home. Concern for surges in hospital occupancy compel emergency providers to preserve inpatient resources and discern which patients benefit most from admission. Even in the absence of surge conditions, patients may prefer to recover at home if safe to do so. However, some patients with Covid-19 experience delayed decompensation.

P019: What happens to John Doe? Unidentified patients in the emergency department: a retrospective chart review

Introduction: Patients who are not identified upon presentation to the emergency department (ED), commonly referred to as John or Jane Does (JDs), are a vulnerable population due to the sequelae associated with this lack of patient information. To date, there has been minimal research describing JDs. We aimed to characterize the JD population and determine if it differs significantly from the general ED population. Methods: We conducted a retrospective chart review of 114 JDs admitted to Saskatoon EDs from May 2018 to April 2019. Patients met inclusion criteria if they were provided a unique JD identification number at ED admission because their identities were unknown or unverifiable. Data regarding demographics, clinical presentation, ED course, mode of identification, and major clinical outcomes (i.e. admission rates, mortality rates) were gathered from electronic records. A second reviewer abstracted a random 21.0% sample of charts to ensure validity of the data. The JD population was then compared to the general population of ED patients that presented during the same time period. Results: Male JDs most commonly presented as trauma activations (85.7%) in contrast to female JDs who most commonly presented with issues related to substance abuse (51.4%). Compared to the general ED population, a greater percentage of JDs were categorized as CTAS 1 or 2 (85.8% vs 18.9%, p &lt; 0.0001), more likely to be 44 years of age or younger (82.4% vs 58.5%, p &lt; 0.0001), and more likely to be male (64.9% vs 49.1%, p &lt; 0.0001). Descriptive statistics on the JD population demonstrated that most JDs received consults to inpatient services (58.8%). Of JDs who presented to the ED, 34.2% were admitted to hospital. The mortality of the JD population was 13.2% at 3 months. The ED average (SD) length of stay for JDs was 8.7 (9.0) hours. How JDs were ultimately identified was recorded only 70.2% of the time. Most frequently, JDs identified themselves (26.3%), other identification methods included police services (14.9%), family members (7.9%), registered nurses (6.1%), government-issued identification (5.3%), social work (4.4%) or other measures (5.4%). Conclusion: JD's represent a unique population in the ED. Both their presentations and clinical outcomes differ significantly from the generalized ED population. More research is needed to better identify strategies to improve the management and identification methods of these unique patients.

Endovascular Therapy for Patients With Acute Ischemic Stroke During the COVID-19 Pandemic: A Proposed Algorithm.

Endovascular Therapy for Patients With Acute Ischemic Stroke During the COVID-19 Pandemic: A Proposed Algorithm.

Impact of endemic HIV on emergency care service delivery in South Africa.

South Africa (SA) has the highest burden of HIV in the world. This study sought to evaluate the impact of high HIV prevalence on the burden of disease in an emergency department (ED). To determine the burden of comorbidities in HIV-positive emergency care patients, their demographic profiles and severity of illness were compared with the general ED population in order to make recommendations for resource allocation and training in EDs in SA. A prospective cross-sectional observational study was conducted from June 2017 to July 2018 in three EDs in Eastern Cape Province. All eligible patients (aged ≥18 years, fully conscious and clinically stable) presenting to the ED during the 6-week study period were approached and asked to give consent for a point-of-care HIV test and collection of demographic information. Simple descriptive statistics were used to analyse data. Log binomial and Poisson models were fitted to estimate prevalence ratios (PRs). Over the total study period, 8 000 patients presented to the ED for care across all sites and 3 537 patients were enrolled. The HIV status of 2 901 individuals (82.0%) was determined. Of those who were screened, 811 (28.0%) were identified as HIV-positive. Medical complaints were more common in HIV-positive patients (n=586, 72.3%) than in trauma patients (n=225, 27.7%). In comparison, HIV-negative patients reported fewer medical complaints (n=1 137, 54.4%) and more trauma (n=953, 45.6%) (p&lt;0.001). HIV-positive patients were more likely to have a life-threatening emergency (n=192, 23.7%) (p=0.004), to be critically ill by triage score (p&lt;0.001) and to be admitted to the hospital (p&lt;0.001) than those who were HIV-negative. Despite high acuity overall, people living with HIV/AIDS were significantly less likely to be deemed critically ill according to vital signs (adjusted PR 0.94; p=0.046). While EDs in SA provide care to high volumes of patients with trauma-related injuries, in areas where HIV prevalence is highest, patients are more likely to present with acute medical emergencies. Providers of emergency care in SA need to be well versed in the management of HIV and associated complications.

Frequency of five unusual presentations in patients with COVID-19: results of the UMC-19-S1

Despite SARS-CoV-19 infection has a stereotypical clinical picture, isolated cases with unusual manifestations have been reported, some of them being well-known to be triggered by viral infections. However, the real frequency in COVID-19 is unknown. Analysing data of 63 822 COVID patients attending 50 Spanish emergency department (ED) during the COVID outbreak, before hospitalisation, we report frequencies of (myo)pericarditis (0.71‰), meningoencephalitis (0.25‰), Guillain-Barré syndrome (0.13‰), acute pancreatitis (0.71‰) and spontaneous pneumothorax (0.57‰). Compared with general ED population, COVID patients developed more frequently Guillain-Barré syndrome (odds ratio (OR) 4.55, 95% confidence interval (CI) 2.09-9.90), spontaneous pneumothorax (OR 1.98, 95% CI 1.40-2.79) and (myo)pericarditis (OR 1.45, 95% CI 1.07-1.97), but less frequently pancreatitis (OR 0.44, 95% CI 0.33-0.60).

Patients with pulmonary hypertension presenting to the emergency department

ObjectivesPulmonary hypertension (PH) patients represent a complex subset of patients in the emergency department (ED), yet little is known about their presentations and outcomes. The objective of this study is to analyze the demographics, dispositions and the rates of return visits for PH patients visiting the ED, focusing on PH patients identified as having high frequency visits. MethodsWe performed a retrospective cohort analysis of all patients with ICD-9-CM and ICD-10-CM codes corresponding to PH presenting to an academic medical center emergency department during a 21-month period. The primary outcome was patients with high frequency ED visits, defined as 4 or more visits in a 12-month period. Secondary outcomes included ED dispositions, return ED visits, hospital length of stay, and in-hospital mortality. ResultsSix hundred and eighty four unique patients with a coded diagnosis of PH visited the emergency department a total of 1447 times. Eighty-four patients (12.28%) were identified as having high frequency visits. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and having Group 1 PH. PH patients’ admission rate was substantial at 56.60%, and their inpatient mortality was increased (6.7% vs 3.7% for all admissions from ED, P < 0.0001). ConclusionPH patients in this study had frequent return ED visits, as well as elevated admission and readmission rates. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and Group 1 PH. PH patients also had increased mortality rates compared to the general ED population.

Use of the Clinical Examination in the Diagnosis of Cardiac Syncope.

Patient history: Age at first syncopal episode older than 35 years = 3.3 History of atrial fibrillation or flutter = 7.3 Known severe structural heart disease = 3.3 to 4.8 Dyspnea prior to syncope = 3.5 Chest pain/angina prior to syncope = 3.4 to 3.8 Cyanotic during syncope = 6.2 Diagnostic tests: High-sensitivity cardiac troponin T > 42 pg/mL = 5.1 High-sensitivity cardiac troponin I > 31.3 pg/mL = 5.4 NT-proBNP ≥ 210.5 pg/mL = 47 NT-proBNP > 1966 pg/mL = 5.8 BNP > 302 pg/mL = 6.3 Multivariable evaluation: Heart disease, abnormal ECG, or both = 2.3 EGSYS score 3 or more = 2.8 to 3.3 Vasovagal score less than −2 = 1.7 to 8.6 Patient history: Age at first syncopal episode 35 years or younger = 0.13 Diagnostic tests: Normal cardiac troponin T or I = 0.15 to 0.39 Normal BNP level = 0.16 to 0.21 Multivariable evaluation: EGSYS score less than 3 = 0.12–0.17 Absence of heart disease, abnormal ECG or both = 0.20 Vasovagal score −2 or more = 0.10–0.84 Syncope or transient loss of consciousness is a common problem seen in the emergency department (ED), accounting for 1% to 1.5% of ED visits annually.1 Cardiac syncope caused by cerebral hypoperfusion secondary to cardiopulmonary events such as arrhythmia or structural heart disease, accounts for 5% to 21% of syncope events.2 Cardiac syncope is associated with an increased risk of premature death and cardiac events.3, 4 It is therefore important for emergency providers to differentiate cardiac syncope from other causes. This systematic review by Albassam et al.5 evaluated patient characteristics, physical examination findings, and diagnostic tests to identify cardiac causes of syncope. The authors searched the MEDLINE, Embase, CINAHL, and Cochrane databases, selecting 11 studies that met inclusion and exclusion criteria. Each study included at least 10 subjects aged 12 years or older, for a total of 4,317 patients. Studies were assigned levels of evidence developed for the Rational Clinical Examination series.6 Several historical factors were associated with an increased likelihood of cardiac syncope including age at first syncopal episode 35 years or older; history of atrial fibrillation or flutter; known severe structural heart disease; dyspnea or chest pain prior to syncope; and witnessed cyanosis during syncope. An elevated cardiac troponin T or I and an elevated B-type natriuretic peptide (BNP) both modestly increased the probability of cardiac syncope. Factors that decreased the probability included age less than 35 years at first syncopal episode; normal cardiac troponin T or I; and normal BNP. Combinations of findings such as Evaluation of Guidelines in Syncope Study (EGSYS) score ≥ 3; vasovagal score < −2; and abnormal electrocardiogram, heart disease, or both were more useful when absent than when present. The results of this review should be interpreted cautiously. Included studies generally defined cardiac syncope based on cardiologist judgment. Five of 11 studies included specialty referral populations or inpatients, leading to the potential for spectrum bias. Applying these results to a general ED population might lead to additional testing or interventions in patients who have lower risk of cardiac syncope than the studied population. Misclassification may have further skewed the results as patients with unexplained syncope were excluded from several studies. Many of the clinical findings resulted from single studies. Studies often included a wide age range of patients despite the incidence of syncope, related ED visits, and serious outcomes increasing sharply after the age of 60.7 Cardiac biomarkers such as troponin or BNP testing appear to be an attractive diagnostic option, however, they did not rule in or rule out cardiac syncope. Moreover, these cardiac biomarkers were likely used to diagnose cardiac syncope leading to incorporation bias. ACEP clinical policy, appreciating these limitations, suggests a risk stratification approach focusing on patient history and physical examination to avoid unnecessary testing and hospital admissions.1 In summary, the accurate diagnosis of cardiac syncope is helpful in determining an appropriate plan of care. While no single variable can independently diagnose or exclude cardiac syncope, several clinical findings may be used cohesively to help guide health care providers.

Refusal of emergency medical care: An analysis of patients who left without being seen, eloped, and left against medical advice.

Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care. This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey. Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%). ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.

The role of cognitive impairment in pain care in the emergency department for patients from residential aged care facilities: a retrospective, case-control study

BackgroundPatients with cognitive impairment are at risk of substantial delays to analgesic medication when presenting to the emergency department in pain. AimTo identify if patients from residential aged care facilities with cognitive impairment experience the same delays to analgesic medication are reported in the general emergency department population. MethodsThis study is a retrospective case-control review of patients presenting to one emergency department with pain as a presenting complaint from residential aged care, with and without cognitive impairment. ResultsPatients without cognitive impairment experience delays in time to first analgesic medication (175min vs 98min, p=0.006) compared to cognitively impaired patients from residential aged care facilities. Both cohorts of patients waited more than three times the national benchmark for analgesic medication and 66% of all patients in this study did not have pain assessment completed. ConclusionPatients presenting from residential caged care facilities in this study without cogitative impairment wait longer for analgesia then patients who present with cogitative impairment, contrary to previously described relationships. Pain assessment and treatment are open to cogitative bias, and in the absence of pain assessment cogitative bias may prevail leading to poor pain care and discrepancies between patients with and without cogitative impairment.

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer.

Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N=1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality. Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values<0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

Healthcare disparities among cancer patients in the emergency department: How do race and ethnicity affect bounce-back rates?

e18150 Background: Previous studies have demonstrated that patients with cancer utilize the emergency department (ED) more frequently than the general population. Additionally, cancer patients are more likely to require a repeat ED visit within 7 days of a preceding ED discharge (bounce back). This may be a marker of inadequate care or missed diagnosis. We designed this study to evaluate whether there are differences in bounce-back rates among cancer patients of different races/ethnicities. Methods: We performed a retrospective cohort study to compare all cancer-related ED visits in California based on race/ethnicity using the Office of Statewide Health Planning and Development (OSHPD) database. We queried all cancer-related ED visits in 2016 among patients ≥18 years and recorded general demographics. Our outcome measures were bounce-back rate and admission rate on the second ED visit. All data were analyzed using SPSS software and descriptive statistics are reported. Results: In 2016, there were 73,465 patients with 103,523 cancer-related ED discharges that met study inclusion criteria. 18% (18,491 visits) of these visits resulted in a bounce-back (versus 13.3% in the general ED population). African American patients had the highest bounce-back rate at 19.5%, followed by Hispanics (18.9%), Non-Hispanic Whites (17.3%) and Asians (17%). We observed an inverse trend in admission rates on the bounce-back visit, with Asian patients having the highest admission rate (40.5%), followed by Non-Hispanic Whites (37.7%), Hispanics (35.1%), and African Americans (32.5%). This is in the context of an overall admission rate of 36.7%, and a high mortality rate on the bounce-back visit of 8.4%. All groups were similar with respect to age, gender, and disease burden. Conclusions: Overall, we observed that African Americans and Hispanics returned to the ED at rates above average, which may be a marker of inadequate care or misdiagnosis. Furthermore, these groups were discharged at a higher frequency on the second visit, despite the high mortality associated with a bounce-back visit. Further investigation is needed to identify actionable targets to improve the emergency cancer care of all races/ethnicities.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments

Study objectivesThe shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in...

Anxiety Screening in the Emergency Department

Background and Hypothesis: &#x0D; Preliminary research completed in the Indiana University Health Methodist Emergency Department (ED) determined that the prevalence of undetected or unaddressed abnormal anxiety levels in patients with low-risk chest pain was greater than 45%. This subset was noted to have abnormal anxiety symptoms that persisted following visits and increased ED recidivism. We hypothesize that the prevalence of abnormal anxiety in the general ED population will be similar to the subset of patients with low-risk chest pain shown previously. &#x0D; Methods: &#x0D; We enrolled a convenience sample of adult patients with non-psychiatric chief complaints who presented to IUH Methodist and Eskenazi Emergency Departments. Participants were assessed for abnormal anxiety levels using the Generalized Anxiety Disorder 7-item Scale (GAD-7) and the Hospital Anxiety Depression Scale (HADS). Subjects will also complete these assessment tools at 30-days post-enrollment via phone or REDCap survey. Data regarding ED disposition, discharge diagnosis, and ED utilization over the previous 12 months and the 30 days post-enrollment will be collected from the electronic medical record (EMR). &#x0D; Results: &#x0D; Over four weeks, 108 patients were screened and 37 gave informed consent and were enrolled. Preliminary analysis shows that 21 subjects (56%) had a GAD-7 score ≥10, indicating abnormal anxiety levels. Full data analysis including comparison of HADS and GAD-7 scores will take place after 50 subjects have been enrolled, completed their 30-day follow-up surveys, and EMR review has taken place. &#x0D; Conclusion: &#x0D; Given data regarding ED visits in patients with low-risk chest pain, identification of anxiety and referral may reduce ED utilization.

Identifying patients with bacterial infections using a combination of C-reactive protein, procalcitonin, TRAIL, and IP-10 in the emergency department: a prospective observational cohort study

ObjectivesThe aim was to effectively reduce the unnecessary use of broad spectrum antibiotics in the emergency department (ED), patients with bacterial infections need to be identified accurately. We investigated the diagnostic value of a combination of biomarkers for bacterial infections, C-reactive protein (CRP), and procalcitonin (PCT), together with biomarkers for viral infections, tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), and interferon-gamma-induced protein-10 (IP-10), in identifying suspected and confirmed bacterial infections in a general ED population with fever. MethodsThis is a sub-study in the HiTEMP cohort. Patients with fever were included during ED triage, and blood samples were obtained. Using both diagnostics and expert panel analysis, all patients were classified as having either suspected or confirmed bacterial infections, or non-bacterial disease. Using multivariable logistic regression analysis, three biomarker models were analysed: model 1, CRP, TRAIL, IP-10; model 2, PCT, TRAIL, IP-10; and model 3, CRP, PCT, TRAIL, IP-10. ResultsA total of 315 patients were included, of whom 228 patients had a suspected or confirmed bacterial infection. The areas under the curve for the combined models were the following: model 1, 0.730 (95% CI 0.665–0.795); model 2, 0.748 (95% CI 0.685–0.811); and model 3, 0.767(95% CI 0.704–0.829). ConclusionsThese findings show that a combination of CRP, PCT, TRAIL and IP-10 can identify bacterial infections with higher accuracy than single biomarkers and combinations of a single bacterial biomarkers combined with TRAIL and IP-10.