High-volume Emergency Department Research Articles

Factors Associated With Head and Neck Polytrauma Presentation and Admissions at Emergency Departments of Varying Sizes.

Timely diagnosis of acute head and neck polytrauma presenting to emergency departments (EDs) optimizes outcomes. Since ED capacity influences triage and admission, the authors utilized the National Electronic Injury Surveillance System database to understand how ED size and trauma characteristics affect head and neck polytrauma presentation and admissions. Demographics and injury characteristics from the National Electronic Injury Surveillance System database from 2018 to 2021 were analyzed to delineate factors contributing to polytrauma presence and admission through multivariable logistic regressions. The authors' 207,951-patient cohort was primarily females (48.6%), non-Hispanic (62.4%), and white (51.4%) people who averaged 57.2 years old. Nonspecific head injuries were predominant (59.7%), followed by facial trauma (22.6%) with rare substance involvement (alcohol, 6.3%; drugs, 4.1%) presenting to high-volume EDs (48.5%). Of the patients, 20% were admitted, whereas 31.1% sustained polytrauma. Substance use [alcohol, odds ratio (OR) = 4.44; drugs, OR = 2.90] increased polytrauma likelihood; neck (OR = 1.35), face (OR = 1.14), and eye (OR = 1.26) associated with polytrauma more than head injuries. Burns (OR = 1.38) increased polytrauma likelihood more than internal organ injuries. Black patients sustained higher polytrauma when presented to non-small EDs (OR = 1.41-1.90) than white patients showed to small EDs. Admissions were higher for males (OR = 1.51). Relative to small EDs, large EDs demonstrated a higher increase in admissions (OR = 2.42). Neck traumas were more likely admitted than head traumas (OR = 1.71). Fractures (OR = 2.21) and burns (OR = 2.71) demonstrated an increased admission likelihood than internal organ injuries. Polytrauma presence and admissions likelihood are site, injury, and substance dependent. Understanding the impact of factors influencing polytrauma presence or admission will enhance triage to optimize outcomes.

The hospital costs of high emergency department pediatric readiness.

We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS)≥88 (0-100 scale) across EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness. We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day-to-day ED operations (ie, direct clinical care and routine ED supplies). The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719-100,694) for low volume EDs to $279,134 (95% CI 196,487-362,179) for very high volume EDs; equipment costs accounted for 0.9-5.0% of expenses. The total annual cost-per-patient ranged from $3/child (95% CI 2-4/child) to $222/child (95% CI 156-288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child. Annual hospital costs for HPR are modest, particularly when considered per child.

Thromboelastography in acute immunologic reactions: a prospective pilot study

BackgroundBiomarkers of fibrinolysis are elevated during acute immunologic reactions (allergic reactions and angioedema), although it is unclear whether fibrinolysis is associated with disease severity. ObjectivesWe investigated a possible association between maximum lysis (ML) measured by thromboelastography and the severity of acute immunologic reactions. MethodsWe recruited patients with acute immunologic reactions at a high-volume emergency department. Clinical disease severity at presentation and at the end of the emergency department stay was assessed using a 5-grade scale, ranging from local symptoms to cardiac arrest. We determined ML on admission by thromboelastography (ROTEM's extrinsic [EXTEM], and aprotinin [APTEM] tests), expressed as ML%. Hyperfibrinolysis was defined as an ML of >15% in EXTEM, which was reversed by adding aprotinin (APTEM). We used exact logistic regression to investigate an association between ML% and disease severity (grades 1 and 2 [mild] vs 3-5 [severe]) and between hyperfibrinolysis and disease severity. ResultsWe included 31 patients (71% female; median age, 52 [IQR, 35-58] years; 10 [32%] with a severe reaction). ML% was higher in patients with severe symptoms (21 [IQR, 12-100] vs 10 [IQR, 4-17]). Logistic regression found a significant association between ML% and symptom severity (odds ratio, 1.07; 95% CI, 1.01-1.21; P = .003). Hyperfibrinolysis was detected in 6 patients and found to be associated with severe symptoms (odds ratio, 17.59; 95% CI, 1.52-991.09; P = .02). D-dimer, tryptase, and immunoglobulin E concentrations increased with the severity of immunologic reactions. ConclusionML, quantified by thromboelastography, is associated with the severity of acute immunologic reactions.

"There hasn't been a push to identify patients in the emergency department"-Staff perspectives on automated identification of candidates for pre-exposure prophylaxis (PrEP): A qualitative study.

Automated algorithms for identifying potential pre-exposure prophylaxis (PrEP) candidates are effective among men, yet often fail to detect cisgender women (hereafter referred to as "women") who would most benefit from PrEP. The emergency department (ED) is an opportune setting for implementing automated identification of PrEP candidates, but there are logistical and practical challenges at the individual, provider, and system level. In this study, we aimed to understand existing processes for identifying PrEP candidates and to explore determinants for incorporating automated identification of PrEP candidates within the ED, with specific considerations for ciswomen, through a focus group and individual interviews with ED staff. From May to July 2021, we conducted semi-structured qualitative interviews with 4 physicians and a focus group with 4 patient advocates working in a high-volume ED in Chicago. Transcripts were coded using Dedoose software and analyzed for common themes. In our exploratory study, we found three major themes: 1) Limited PrEP knowledge among ED staff, particularly regarding its use in women; 2) The ED does not have a standardized process for assessing HIV risk; and 3) Perspectives on and barriers/facilitators to utilizing an automated algorithm for identifying ideal PrEP candidates. Overall, ED staff had minimal understanding of the need for PrEP among women. However, participants recognized the utility of an electronic medical record (EMR)-based automated algorithm to identify PrEP candidates in the ED. Facilitators to an automated algorithm included organizational support/staff buy-in, patient trust, and dedicated support staff for follow-up/referral to PrEP care. Barriers reported by participants included time constraints, hesitancy among providers to prescribe PrEP due to follow-up concerns, and potential biases or oversight resulting from missing or inaccurate information within the EMR. Further research is needed to determine the feasibility and acceptability of an EMR-based predictive HIV risk algorithm within the ED setting.

Automated volumetric evaluation of intracranial compartments and cerebrospinal fluid distribution on emergency trauma head CT scans to quantify mass effect.

Intracranial space is divided into three compartments by the falx cerebri and tentorium cerebelli. We assessed whether cerebrospinal fluid (CSF) distribution evaluated by a specifically developed deep-learning neural network (DLNN) could assist in quantifying mass effect. Head trauma CT scans from a high-volume emergency department between 2018 and 2020 were retrospectively analyzed. Manual segmentations of intracranial compartments and CSF served as the ground truth to develop a DLNN model to automate the segmentation process. Dice Similarity Coefficient (DSC) was used to evaluate the segmentation performance. Supratentorial CSF Ratio was calculated by dividing the volume of CSF on the side with reduced CSF reserve by the volume of CSF on the opposite side. Two hundred and seventy-four patients (mean age, 61 years ± 18.6) after traumatic brain injury (TBI) who had an emergency head CT scan were included. The average DSC for training and validation datasets were respectively: 0.782 and 0.765. Lower DSC were observed in the segmentation of CSF, respectively 0.589, 0.615, and 0.572 for the right supratentorial, left supratentorial, and infratentorial CSF regions in the training dataset, and slightly lower values in the validation dataset, respectively 0.567, 0.574, and 0.556. Twenty-two patients (8%) had midline shift exceeding 5 mm, and 24 (8.8%) presented with high/mixed density lesion exceeding >25 ml. Fifty-five patients (20.1%) exhibited mass effect requiring neurosurgical treatment. They had lower supratentorial CSF volume and lower Supratentorial CSF Ratio (both p < 0.001). A Supratentorial CSF Ratio below 60% had a sensitivity of 74.5% and specificity of 87.7% (AUC 0.88, 95%CI 0.82-0.94) in identifying patients that require neurosurgical treatment for mass effect. On the other hand, patients with CSF constituting 10-20% of the intracranial space, with 80-90% of CSF specifically in the supratentorial compartment, and whose Supratentorial CSF Ratio exceeded 80% had minimal risk. CSF distribution may be presented as quantifiable ratios that help to predict surgery in patients after TBI. Automated segmentation of intracranial compartments using the DLNN model demonstrates a potential of artificial intelligence in quantifying mass effect. Further validation of the described method is necessary to confirm its efficacy in triaging patients and identifying those who require neurosurgical treatment.

Patient sex, racial and ethnic disparities in emergency department triage: A multi-site retrospective study

ObjectivesThere is limited evidence on sex, racial, and ethnic disparities in Emergency Department (ED) triage across diverse settings. We evaluated differences in the assignment of Emergency Severity Index (ESI) by patient sex and race/ethnicity, accounting for age, clinical factors, and ED operating conditions. MethodsWe conducted a multi-site retrospective study of adult patients presenting to high-volume EDs from January 2019–February 2020. Patient-level data were obtained and analyzed from three EDs (academic, metropolitan community, and rural community) affiliated with a large health system in the Southeastern United States. For the study outcome, ESI levels were grouped into three categories: 1–2 (highest acuity), 3, and 4–5 (lowest acuity). Multinomial logistic regression was used to compare ESI categories by patient race/ethnicity and sex jointly (referent = White males), adjusted for patient age, insurance status, ED arrival mode, chief complaint category, comorbidity score, time of day, day of week, and average ED wait time. ResultsWe identified 186,840 eligible ED visits with 56,417 from the academic ED, 69,698 from the metropolitan community ED, and 60,725 from the rural community ED. Patient cohorts between EDs varied by patient age, race/ethnicity, and insurance status. The majority of patients were assigned ESI 3 in the academic and metropolitan community EDs (61% and 62%, respectively) whereas 47% were assigned ESI 3 in the rural community ED. In adjusted analyses, White females were less likely to be assigned ESI 1–2 compared to White males although both groups were roughly comparable in the assignment of ESI 4–5. Non-White and Hispanic females were generally least likely to be assigned ESI 1–2 in all EDs. Interactions between ED wait time and race/ethnicity-sex were not statistically significant. ConclusionsThis retrospective study of adult ED patients revealed sex and race/ethnicity-based differences in ESI assignment, after accounting for age, clinical factors, and ED operating conditions. These disparities persisted across three different large EDs, highlighting the need for ongoing research to address inequities in ED triage decision-making and associated patient-centered outcomes.

Concurrent Testing for COVID-19 and HIV Infection at 6 High-Volume Emergency Departments in a Priority Jurisdiction for Ending the HIV Epidemic in the United States.

The COVID-19 pandemic caused disruptions in access to routine HIV screening. We assess HIV and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing across 6 emergency departments (EDs) in Cook County, Illinois. We retrospectively analyzed the number of SARS-CoV-2 tests, HIV screens, and the proportion of concurrent tests (encounters with both SARS-CoV-2 and HIV testing), correlating with diagnoses of new and acute HIV infection. Five sites reported data from March 1, 2020, to February 28, 2021, and 1 site from September 1, 2020, to February 28, 2021. A total of 1,13,645 SARS-CoV-2 and 36,094 HIV tests were performed; 17,469 of these were concurrent tests. There were 102 new HIV diagnoses, including 25 acute infections. Concurrent testing proportions ranged from 6.7% to 37% across sites (P < 0.001). HIV testing volume correlated with the number of new diagnoses (r = 0.66, P < 0.01). HIV testing with symptomatic SARS-CoV-2 testing was strongly correlated with diagnosis of acute infections (r = 0.87, P < 0.001); this was not statistically significant when controlling for HIV testing volumes (r = 0.59, P = 0.056). Acute patients were more likely to undergo concurrent testing (21/25) versus other new diagnoses (29/77; odds ratio = 8.69, 95% CI: 2.7 to 27.8, P < 0.001). Incorporating HIV screening into SARS-CoV-2 testing in the ED can help maintain HIV screening volumes. Although all patients presenting to the ED should be offered opt-out HIV screening, testing individuals with symptoms of COVID-19 or other viral illness affords the opportunity to diagnose symptomatic acute and early HIV infection, rapidly link to care, and initiate treatment.

Clinical Characteristics of Atrial Flutter and Its Response to Pharmacological Cardioversion with Amiodarone in Comparison to Atrial Fibrillation.

Unlike atrial fibrillation (AF), atrial flutter (AFl) is thought to be relatively refractory to pharmacological cardioversion (PC), but the evidence is scarce. The aim of this study was to evaluate the clinical characteristics and efficacy of the PC of AFl with amiodarone in comparison to AF. This retrospective study covered 727 patients with urgent consult for AF/AFl in a high-volume emergency department between 2015 and 2018. AFl was diagnosed in 222 (30.5%; median age: 68 (62; 75) years; 65.3% men). In a nested case-control study, 59 control patients with AF, matched in terms of age and sex with 60 AFl patients, were subject to PC with amiodarone. The primary endpoint was return of sinus rhythm confirmed using a 12-lead ECG. The AFl population had a median CHA2DS2-VASc score of 3 (2; 4) and episode duration of 72 h (16; 120). In the AFl cohort, 36% of patients were initially subject to PC, 33.3% to electrical cardioversion (EC) and 40.5% to catheter ablation. In comparison to the AF group, the AFl patients required a longer hospitalization time, had a higher rate of EC (p < 0.001) and less frequent use of PC (p < 0.001) and, lower left ventricular ejection fraction (p < 0.001) and more pronounced cardiovascular risk factors. The efficacy of PC with amiodarone was significantly lower in AFl than AF group (39% vs. 65%, relative risk (RR) 0.60, p = 0.007). AFl patients shared a greater burden of comorbidities than AF patients, while the efficacy of PC in AFl was low. Patients should be initially managed with primary electrical cardioversion.

A scalable approach to determine cervical cancer screening needs among emergency department patients in the United States

The emergency department patient population is disproportionately under-screened for cancer, making it an optimal environment to promote cancer screening among hard-to-reach populations and those without routine access to primary care. The first step in a cancer screening process is identifying screening eligibility (e.g. age, sex) and need (i.e. due or past due). In an effort to support the scalability of an emergency department (ED)-based cervical cancer screening intervention, we examined the performance of a low-resource approach of determining cervical cancer screening needs among ED patients. A convenience sample of ED patients (N = 2807) was randomized to (a) an in-person interview with human subjects research staff or, (b) a self-administered, tablet computer-based survey for determining cervical cancer eligibility and need. Patients were recruited from a high-volume urban ED in Rochester, NY and a low-volume rural ED in Dansville, NY between December 2020 and December 2022. Results of these approaches were compared for equivalence of method for determining adherence status with screening guidelines and under/over-reporting of screening activity. Nearly identical reported rates of non-adherence with screening were identified across conditions (1.7% absolute difference; Χ21 = 0.96, p = 0.33). Our results demonstrate that a low-resource approach of using a tablet-based self-administered survey to determine cervical cancer screening needs is equivalent to a labor intensive in-person interview approach conducted by trained research staff among ED patients.

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease.

Emergency department (ED) crowding leads to poor outcomes. Patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) are especially vulnerable to crowding-related delays in care. We aimed to assess the associations of ED crowding metrics with outcomes for patients presenting with COPD. We conducted a population-based cohort study of adult patients presenting with a diagnosis of COPD to 18 high-volume EDs between 2014 and 2019 in Alberta, Canada. Administrative databases provided date and time data on key stages of the presentation including physician initial assessment and disposition decision. Crowding metrics were calculated using facility-specific median physician initial assessment and length of stay. Patient presentations were grouped by acuity and mixed-effects regression models were fit to adjust for the clustering at the facility level. There were 49,085 presentations for COPD made by 25,734 patients (median age = 73years). A 1-h increase in the physician initial assessment metric was associated with an increase in physician initial assessment for COPD patients by 23, 53, and 59min for the high, moderate, and low acuity groups, respectively, adjusted for other predictors. For the low acuity group, this metric was associated with an increased length of stay of 73min for admitted individuals. Similarly, an increase in the length of stay metric was also associated with an increased likelihood of being admitted for all acuity groups. For patients with COPD, ED crowding results in delays in assessment increased length of stay, and increased proportion of patients admitted. These results suggest that ED crowding mitigation efforts to provide timely care for patients with COPD are urgently needed. N/A.

Most Common Ophthalmic Diagnoses in Eye Emergency Departments: A Multicenter Study

To characterize the most common ophthalmic conditions seen in the emergency department (ED) DESIGN: Cross-sectional study METHODS: This is a multicenter study of 64,988 patients who visited the Bascom Palmer Eye Institute, Massachusetts Eye and Ear, Wills Eye Hospital, and Johns Hopkins Hospital/Wilmer Eye Institute from January 1, 2019, until December 31, 2019. Demographic and primary diagnosis data were extracted including gender, age, race, ethnicity, insurance type, and ophthalmology consult status. Descriptive statistics were performed on all data using STATA IC 14 (64-bit). A total of 64,988 patients with primary ocular diagnoses were seen across all 4 EDs. The majority of patients were White (63.1%), non-Hispanic/Latino (64.8%), and female (52.3%). The most frequently seen age group was 50-64 years (28.6%). The most common diagnoses across all institutions were conjunctivitis (7.91%), corneal abrasions (5.61%), dry eye (4.49%), posterior vitreous detachments (4.15%), chalazions (3.71%), corneal ulcers (3.01%), subconjunctival hemorrhages (2.96%), corneal foreign bodies (2.94%), retinal detachments (2.51%), and glaucoma (2.12%). Specifically, viral conjunctivitis (2283 of 5139, 44.4%) and primary open-angle glaucoma (382 of 1379, 27.7%) were the most frequently seen subtypes of conjunctivitis and glaucoma. The most regularly treated ophthalmic conditions in high-volume EDs tend to be lower acuity diagnoses. To combat ED overcrowding and rising health care costs in the United States, we suggest diverting eye-related ED visits to a specialized eye ED service or same-day eye clinic appointment in addition to expanding education for patients and primary care clinicians.

Emergency department crowding negatively influences outcomes for adults presenting with asthma: a population-based retrospective cohort study

BackgroundAccess to emergency department (ED) services is important for patients with acute asthma; however, ED crowding may impact the quality of care and compromise outcomes. We examine the association between ED crowding metrics and individual patient outcomes for adults presenting with asthma.MethodsThis population-based retrospective cohort study extracted all ED presentations made by patients aged 18 to 55 years to 18 high-volume EDs in Alberta from April 2014 to March 2019. Physician initial assessment (PIA) time and ED length of stay (LOS) for discharged and admitted patients were calculated. Other metrics and patient outcomes were also obtained. Linear and generalized linear models were fit for continuous and categorical outcomes. Cox proportional hazards models were used for time-to-event outcomes.ResultsThere were 17,724 ED presentations by 12,569 adults. The median age was 33 years, and females (58.7%) made more presentations. ED crowding affected the PIA time for all triage groups. For the high acuity group (Canadian Triage and Acuity Scale [CTAS] 1/2), 1 h increase in median facility-specific PIA was associated with 26 min (95%CI: 24,28) increase; for the moderate acuity (CTAS 3) and low acuity (CTAS 4/5) groups, the individual-level PIA increased by 54 min (95%CI: 53,55) and 61 min (95%CI: 59,63), respectively adjusted by other predictors. Increases in facility PIA resulted in increase in odds of admissions for the high acuity group and increase odds of left without completion of care for the moderate and low acuity groups.ConclusionThe care provided for patients from all triage groups was impacted when EDs experienced crowding. Effective interventions are needed to mitigate ED crowding and improve care and outcomes for this important patient group.

The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA).

The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians. We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate. There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5). Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.

A Comparison of Univariate and Multivariate Forecasting Models Predicting Emergency Department Patient Arrivals during the COVID-19 Pandemic.

The COVID-19 pandemic has heightened the existing concern about the uncertainty surrounding patient arrival and the overutilization of resources in emergency departments (EDs). The prediction of variations in patient arrivals is vital for managing limited healthcare resources and facilitating data-driven resource planning. The objective of this study was to forecast ED patient arrivals during a pandemic over different time horizons. A secondary objective was to compare the performance of different forecasting models in predicting ED patient arrivals. We included all ED patient encounters at an urban teaching hospital between January 2019 and December 2020. We divided the data into training and testing datasets and applied univariate and multivariable forecasting models to predict daily ED visits. The influence of COVID-19 lockdown and climatic factors were included in the multivariable models. The model evaluation consisted of the root mean square error (RMSE) and mean absolute error (MAE) over different forecasting horizons. Our exploratory analysis illustrated that monthly and weekly patterns impact daily demand for care. The Holt–Winters approach outperformed all other univariate and multivariable forecasting models for short-term predictions, while the Long Short-Term Memory approach performed best in extended predictions. The developed forecasting models are able to accurately predict ED patient arrivals and peaks during a surge when tested on two years of data from a high-volume urban ED. These short- and long-term prediction models can potentially enhance ED and hospital resource planning.

Impact of a rapid high-sensitivity troponin pathway on patient flow in an urban emergency department.

Study ObjectiveTo evaluate whether the introduction of a 1‐hour high‐sensitivity cardiac troponin‐T (hs‐TnT) pathway for patients who present to the emergency department (ED) with suspected acute coronary syndrome (ACS) improves ED patient flow without changing the rate of “missed” major adverse cardiac events (MACE), compared to use of conventional cardiac troponin with an associated 3‐hour pathway.MethodsThis was a prospective, uncontrolled observational study conducted before and after implementation of a 1‐hour hs‐TnT pathway at a high‐volume urban ED. Patients undergoing evaluation for ACS in the ED were enrolled during their initial visit and clinical outcomes were assessed at 30 and 90 days. Throughput markers were extracted from the electronic medical record and compared. The primary outcome was provider‐to‐disposition decision time.ResultsA total of 1892 patients were enrolled, 1071 patients while using conventional troponin and 821 after introduction of hs‐TnT. With the new assay and pathway, median interval between troponin tests decreased from 4.7 hours (interquartile range [IQR] 3.9–5.7 hours) to 2.3 hours (IQR 1.5–3.4 hours) (P < 0.001). However, there was no difference in median provider‐to‐disposition decision time, which measured 4.7 hours (IQR 2.9–7.2) and 4.8 hours (IQR 3.1–7.1) (P = 0.428) respectively. Total 30‐day MACE rate in discharged patients was low in both groups, occurring in only 4/472 (0.85%) encounters in the first cohort and 4/381 (1.0%) encounters in the second.ConclusionIntroduction of a 1‐hour hs‐TnT ACS evaluation pathway reduced the troponin collection interval but did not reduce provider to disposition time. There was no difference in rate of 30‐day MACE in patients discharged from the ED.

Implementation of Columbia Suicide Severity Rating Scale (C-SSRS) as a Universal Suicide Risk Screening tool in a High Volume Emergency Department

Objective To examine clinical and demographic parameters with regards to efficacy, resource utilization, and clinician burden associated with implementation of universal suicide screening by Columbia Suicide Severity Rating Scale (C-SSRS) in a single high-volume emergency department. Methods This retrospective cohort study, performed via chart review, included 10,197 adult patients seen in the emergency department over two specific time frames (4935 pre- and 5262 post-implementation of the screening tool). All visits with psychiatry consultation underwent further chart review (172 pre- and 217 post-) to compare number, length of stay (LOS) and demographics for psychiatric evaluations pre- and post- use of C-SSRS screening. Results Both groups were predominantly male with previous psychiatric diagnoses. Within the post-screening group, individuals tended to be older with lower likelihood of previously diagnosed psychiatric illness. No significant differences were seen in gender, psychiatric diagnosis, or outpatient psychiatric treatment. Incidence of psychiatric evaluation was slightly higher post-screening (18%) without meeting statistical significance, with more patients discharged home in the post- cohort. LOS was slightly lower after implementation of C-SSRS, without reaching statistical significance. Conclusions Implementation of universal screening showed increased demand for psychiatric evaluations, without meeting clinical significance in this limited analysis. Although there were slightly more psychiatric evaluations, more patients were discharged to home. LOS showed no statistical increase, even trending toward shorter duration for patients screened to be evaluated by psychiatry. Based on these results, efficient suicide screening may help identify at-risk individuals without overwhelming psychiatric resources or causing unnecessary increase in LOS. Highlights Rapid identification of suicide risk is important in an emergency department environment. Universal suicide screening has limitations, with concerns for emergency department resources. Use of C-SSRS for universal screening does not show significant burden to this department.

The Feasibility of Ultra-Sensitive Phonocardiography in Acute Chest Pain Patients of a Tertiary Care Emergency Department (ScorED Feasibility Study)

Background: Thoracic pain is one of the most frequent chief complaints at emergency departments (EDs). However, a respective workup in cases without clear electrocardiographic signs is complex. In addition, after having ruled out acute coronary syndrome (ACS), patients are often left with an unclear etiology of their symptoms. Ultra-sensitive phonocardiography is already used to rule out stable coronary artery disease (CAD); however, its feasibility in an ED-setting remains unknown. Methods: We prospectively used ultra-sensitive phonocardiography via the CADScor®System to measure hemodynamically stable patients with the chief complaint of chest pain during routine waiting times at a high-volume tertiary ED. Results: A total of 101 patients (49% male; 94% Caucasian; 61 (51–71) years; BMI 28.3 (24.2–31.6)) were enrolled. Patient workflow was not hindered, and no adverse events were recorded. In 80% of cases, a score was successfully calculated, with 74% at the first, 5% at the second, and 1% at the third attempt. Feasibility was judged as 9.0 (±1.8) by the patients, and 8.9 (±2.6) by the investigators on a 10-point Likert scale. Conclusions: Ultra-sensitive phonocardiography was found to be feasible in acute chest pain patients presenting to a tertiary ED. Thus, the CAD score measured during routine waiting times could potentially serve as an additional tool in a diagnostic pathway for thoracic pain.

Suicide Attempts by Poisoning: An Experience From a High-Volume Emergency Department.

BackgroundThere has been a tremendous increase in self-poisoning behavior worldwide, with different trends depending on cultural and geographic aspects.ObjectivesOur study aims to assess the trends, outcomes, and predictors in patients of suicide attempts by poisoning at King Abdulaziz Medical City (KAMC) ED.Materials and methodsA retrospective cohort study took place at KAMC. Frequencies and percentages were used to display categorical variables. Minimum, maximum, mean, and SD were used to display continuous variables. Chi-squared test and independent t-test were utilized to test for factors associated with suicidal intention.ResultsA total of 130 cases were identified. The participants were mostly females (73.8%, n = 96). Most of the participants were pediatric patients (57.7%, n = 75). The most consumed agents were acetaminophen in 59 (45.83%) and non-steroidal anti-inflammatory drugs (NSAIDs) in 22 (16.92%). The ICU admission rate was 8.5% (n = 11). The management for both populations was unspecific, involving observation, supportive measures, and symptomatic treatment. BMI (p < 0.001), gender (p < 0.001), age (p = 0.012), and a history of neuropsychiatric disorders (p < 0.001) were associated factors.ConclusionIt is crucial that the trends and risk factors of self-poisoning suicide attempts are identified to provide support to those in need. Several variables of interest were noted since the two most observed agents share several key features, such as accessibility and availability. However, contradicting literature reports warrant further investigation to confirm or negate the evidence.

Emergency department non-contrast computed tomography for suspicion of obstructive urolithiasis: Yield and consequences.

We aimed to analyze patterns of referral, yield, and clinical implications of non-contrast computed tomography (NCCT) in the acute evaluation of flank pain suspected as obstructive urolithiasis (OU) in a high-volume emergency department (ED). The study comprised 506 consecutive NCCTs performed in the ED over four months. Detection rates of OU, incidental, and alternative findings were calculated. Imaging signs suspicious for recent passage of stones were considered positive for OU, while renal stones without signs of obstruction were considered unrelated to the acute presentation. OU, other findings requiring hospitalization, and incidental findings warranting further workup were considered situations in which NCCTs were warranted. NCCTs confirmed an OU diagnosis in 162 (32%) patients and non-clinically significant nephrolithiasis in 125 (25%). They revealed other findings in 108 (21%) patients, including 42 (8%) with clinically significant incidental findings and 26 (5%) with alternative diagnoses requiring hospitalization. NCCTs were entirely negative in 111 (22%) patients. Corroboration of these outcomes, together with overlapping of OU, incidental, and alternative significant findings in some patients resulted in an overall justified NCCT request rate of 44%. The yield of NCCT performed in acute presentations of flank pain suspected as OU is relatively low, and over one-half of the scans are unwarranted. The pattern of requesting NCCT in the ED needs refinement to avoid abuse that may lead to radiation overexposure, psychological burden, physical harm, and financial overload.

Abstract WP34: Bed Ahead Process Avoids The Thrombectomy Patient Boarding In Emergency Department

Background: University Hospitals Comprehensive Stroke Center (UH CSC) is an academic medical center with a dedicated 19 bed Neuroscience Intensive Care unit (NSU). As the only comprehensive stroke center in a 22 hospital system, the majority of ischemic stroke patients requiring a mechanical thrombectomy procedure are transferred to the UH CSC. A post thrombectomy patient requires intensive monitoring to assess for complications and is best cared for by highly trained neuro nurses in an intensive care environment. Lack of available NSU beds often resulted in these patients returning to the high volume emergency department with less than ideal staffing. The request for a NSU bed was not initiated until the thrombectomy procedure began delaying the chain of events that lead to an available NSU bed. Hypothesis: A proactive process that would initiate obtaining a NSU bed sooner would avoid these patients from boarding in the emergency department. Methods: Key stake holders from the stroke program, neurocritical care, emergency medicine, neuro interventional and the transfer center met in early 2019 to review data and quality concerns. An algorithm was developed and shared with all staff. Once the stroke faculty accepts a transfer of a potential thrombectomy patient, the new process includes notifying the NSU fellow and charge nurse to initiate making an open bed before the patient arrives to UH CSC. Results: In 2018, 48% of patients that underwent a mechanical thrombectomy returned to the emergency department. After the implementation of the new process the percentage of patients returning to the emergency department declined to 28% in 2019. In 2020 only 8% returned to the emergency department. The number of quality concerns significantly decreased. Conclusion: The bed ahead process initiated before a thrombectomy patient arrives at the comprehensive stroke center has been successful in avoiding returns to the emergency department and meeting our goal to achieve high quality patient outcomes and improve care efficiency.