Hospital-based Emergency Department Research Articles

Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study

BackgroundTransferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios.MethodsA Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics.ResultsSeventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions.ConclusionsTransfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments

Background: Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees. Methods: Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards. Results: There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time. Conclusion: Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.

Prevalence of frailty and associated factors in older adults seeking care at Swedish emergency departments

BackgroundInternationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited.AimTo describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs.MethodsThe study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes.ResultsA total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care.ConclusionOur study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.

Computed Tomography Utilization for Patients Presenting with Chest Pain

IntroductionComputed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain. MethodsA retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 – April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain. ResultsThere were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81–0.90). ConclusionCT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study.

The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

Exploring Which Patients Use Their Closest Emergency Departments Using Geocoded Data

BackgroundEach year, roughly 20% of U.S. adults visit an emergency department (ED), but little is known about patients’ choice of ED. ObjectivesExamine the discretion patients have to choose among EDs, characteristics associated with ED choice, and relationship between ED choice and self-reported care experiences of ED patients. MethodsWe surveyed adult patients discharged to the community (DTC) in January–March 2018 from 16 geographically dispersed hospital-based EDs, geocoded patient and hospital-based ED addresses within 100 miles of patient addresses, and calculated travel distances. We examined the likelihood of visiting the closest ED based on patient and ED characteristics. Linear regression models examined the association of choosing the closest ED with seven measures of patient experience of care (scaled 0–100), adjusting for patient characteristics. Results43.6% of 4647 responding patients visited the ED nearest their home (on average, 5.7 miles away). Patients who chose a farther ED had more urgent conditions, were more educated, and were less likely to be non-Hispanic White. They were significantly more likely to have visited an ED in a higher-rated, metropolitan, network hospital with major teaching status, a cardiac intensive care unit, and a certified trauma center. Patients who chose a farther ED were more likely to recommend that ED, with “medium-to-large” differences in scores (+4.3% more selected “definitely yes”, p < 0.05). ConclusionsFewer than half of patients visited the closest ED. Patients who chose a farther ED tended to seek higher-rated hospitals and report more favorable experiences.

MP06-14 QUALITY METRICS FOR PATIENTS REQUIRING URGENT SURGICAL INTERVENTION - COMPARING A FREESTANDING EMERGENCY DEPARTMENT TO A HOSPITAL-BASED EMERGENCY DEPARTMENT

You have accessJournal of UrologyCME1 Apr 2023MP06-14 QUALITY METRICS FOR PATIENTS REQUIRING URGENT SURGICAL INTERVENTION - COMPARING A FREESTANDING EMERGENCY DEPARTMENT TO A HOSPITAL-BASED EMERGENCY DEPARTMENT Ginnie Jeng, Alexa Meyer, Adam Hass, Eric Cruzen, Yves Duroseau, and Lee Richstone Ginnie JengGinnie Jeng More articles by this author , Alexa MeyerAlexa Meyer More articles by this author , Adam HassAdam Hass More articles by this author , Eric CruzenEric Cruzen More articles by this author , Yves DuroseauYves Duroseau More articles by this author , and Lee RichstoneLee Richstone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the past decade, there has been a dramatic increase in the number of freestanding emergency departments (EDs) affiliated and located near existing hospital-based EDs. Given freestanding EDs do not have in-house surgical specialty providers, the purpose of this study was to determine whether differences exist in the quality of care and clinical outcomes of patients presenting to freestanding versus hospital-based EDs for urgent surgical conditions. METHODS: Retrospective analysis of patients that presented to Lenox Health Greenwich Village (freestanding) and Lenox Hill Hospital (hospital-based) EDs in New York City between 01/2019 and 02/2021 with urgent surgical conditions was performed. Data collected include patient demographics, ED and procedure time data, principal diagnosis and procedure, and post-operative data. Statistical analyses include Mann-Whitney test, Chi square test, COX regression, and logistic regression, with p<0.05 considered statistically significant. RESULTS: 1220 patient were included in this study, with 356 presenting to freestanding and 864 to hospital-based ED for surgically urgent conditions, including testicular torsion (Table 1). Median times from ED arrival to surgical intervention were 14.7 hours in freestanding and 12.7 hours in hospital-based ED (p=0.073). Factors associated with significantly longer time intervals include African American race (HR=0.75, 95% CI: 0.57-0.90), Medicaid (HR=0.80, 95% CI: 0.68-0.95), and Medicare (HR=0.63, 95% CI: 0.49-0.81). Patients who presented to freestanding ED had significantly shorter ED length of stay (p<0.0001) and more accurate ED diagnoses (p=0.022). There were no statistical differences in ICU admission (p=0.188), post-operative complication (p=0.957), 30-day readmission (p=0.256), and mortality rates (p=0.524) between the two groups. CONCLUSIONS: Within our system, the quality of care and clinical outcomes of patients requiring urgent surgical intervention are comparable for those presenting to a freestanding ED versus a hospital-based ED. Thus, freestanding EDs in an urban environment may be beneficial for both patients and health care facilities. However, differences in care across race and insurance group must be further explored. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e58 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ginnie Jeng More articles by this author Alexa Meyer More articles by this author Adam Hass More articles by this author Eric Cruzen More articles by this author Yves Duroseau More articles by this author Lee Richstone More articles by this author Expand All Advertisement PDF downloadLoading ...

The role of social connections and support in the use of emergency care among older adults

ObjectivesLimited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. MethodsThis is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. ResultsMedium (IRR 0.77; 95% CI 0.59–0.99) and high (IRR 0.77; 95% CI 0.56–0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. ConclusionsED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults.

Health care provider reporting practices related to self-managed abortion

BackgroundHealth care providers reporting patients to government authorities is a main way people attempting self-managed abortion (SMA) become exposed to legal risks. Little is known about health care provider decision-making regarding SMA reporting.MethodsWe conducted semi-structured interviews with 37 clinicians who provided care in hospital-based obstetrics or emergency departments (13 obstetricians/gynecologists, two advance practice registered nurses providing obstetrics care, 12 emergency medicine physicians, and 10 family medicine physicians) throughout the United States. The interview guide asked participants to describe one or more cases of caring for a patient who may have attempted SMA and about related reporting decisions. We coded responses to answer two questions: What comes to mind for health care providers when asked to think about experiences caring for a patient who may have attempted SMA? Based on health care provider experiences, how might people who providers suspect may have attempted SMA end up reported?ResultsAbout half of participants had cared for someone who may have attempted SMA for that pregnancy. Only two mentioned SMA with misoprostol. Most participants described cases where they were unsure whether the patient had attempted to end their pregnancy on purpose. In most instances, participants mentioned that that the possibility of reporting never occurred to them nor came up. In some cases, participants described a reporting “adjacent” practice – e.g. beginning processes that could lead to substance use, domestic violence, or self-injury/suicide-related reports – or considered reporting related to a perceived need to report abortion complications. In two cases, hospital staff reported to the police and/or Child Protective Services related to the SMA attempt. These involved passing of a fetus after 20 weeks outside the hospital and a domestic violence incident.ConclusionReporting patients who may have attempted SMA may occur via provider perception of a need to report abortion complications and fetal demises, particularly at later gestations, and other reporting requirements (e.g. substance use, domestic violence, child maltreatment, suicide/self-harm).

Evaluation of missed influenza vaccination opportunities in the emergency department

BackgroundSeasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018–2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. MethodsThis was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 – April 30) over a two-years, 2018–2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. ResultsA total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. ConclusionPatients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Impact of enhancing GP access to diagnostic imaging: A scoping review.

Direct access to diagnostic imaging in General Practice provides an avenue to reduce referrals to hospital-based specialities and emergency departments, and to ensure timely diagnosis. Enhanced GP access to radiology imaging could potentially reduce hospital referrals, hospital admissions, enhance patient care, and improve disease outcomes. This scoping review aims to demonstrate the value of direct access to diagnostic imaging in General Practice and how it has impacted on healthcare delivery and patient care. A search was conducted of 'PubMed', 'Cochrane Library', 'Embase' and 'Google Scholar' for papers published between 2012-2022 using Arksey and O'Malley's scoping review framework. The search process was guided by the PRISMA extension for Scoping Reviews checklist (PRISMA-ScR). Twenty-three papers were included. The studies spanned numerous geographical locations (most commonly UK, Denmark, and Netherlands), encompassing several study designs (most commonly cohort studies, randomised controlled trials and observational studies), and a range of populations and sample sizes. Key outcomes reported included the level of access to imaging serves, the feasibility and cost effectiveness of direct access interventions, GP and patient satisfaction with direct access initiatives, and intervention related scan waiting times and referral process. Direct access to imaging for GPs can have many benefits for healthcare service delivery, patient care, and the wider healthcare ecosystem. GP focused direct access initiatives should therefore be considered as a desirable and viable health policy directive. Further research is needed to more closely examine the impacts that access to imaging studies have on health system operations, especially those in General Practice. Research examining the impacts of access to multiple imaging modalities is also warranted.

Fundamental nursing actions for frail older people in the emergency department: A national cross-sectional survey and a qualitative analysis of practice guidelines.

To map how frailty among older people is assessed at Swedish emergency departments and to describe fundamental nursing care actions for these patients. Descriptive national survey and a qualitative analysis of text. A majority (82%, n=54) of the Swedish hospital-based emergency departments for adults were included, representing all six healthcare regions. An online survey was used to collect data, together with submitted local practice guidelines for older people at the emergency departments. Data were collected during February-October 2021. Descriptive and comparative statistics were performed together with a deductive content analysis framed by the Fundamentals of Care framework. Sixty-five per cent (35 of 54) of the emergency departments identified frailty, with less than half of them using an established assessment instrument. Twenty-eight (52%) of the emergency departments have practice guidelines containing fundamental nursing actions for the care of frail older people. The majority of nursing actions in the practice guidelines were related to patients' physical care needs (91%), followed by psychosocial care needs (9%). No actions could be identified as relational actions (0%) according to the Fundamentals of Care framework. Many Swedish emergency departments identify frail older people, but they use a range of different assessment instruments. While practice guidelines directing fundamental nursing actions for frail older people are often in place, a holistic, person-centred view addressing the patient's physical, psychosocial and relational care needs is missing. The population is growing older, and more people are needing more complex hospital care. Frail older people have an increased risk of negative outcomes. The use of a variety of assessment instruments for frailty may pose a challenge to equal care. To ensure a holistic, person-centred view of frail older people, the Fundamentals of Care framework can be used in developing and reviewing practice guidelines. Clinicians and non-health professionals were invited to review the survey to ensure face and content validity.

Using Space Syntax Analysis to Measure Patient Aggression Risk.

The present study investigates whether space syntax offers appropriate tools for identifying risks of aggression, interventional opportunities, and environmental design strategies to reduce the risk of Type II violence in emergency departments. Although healthcare workers are a relatively small percentage of the U.S. workforce, they sustain almost 75% of workplace assaults. Poor environmental design has been identified as an antecedent to aggression by patients and/or their companions. Guided by Rational Choice Theory, Lifestyle Exposure Theory, Routine Activity Theory, and Crime Prevention through Environmental Design (CPTED), the study uses five visibility graph analysis (VGA) measures: visibility, control, controllability, mean visual depth, and occlusivity. Three U.S. hospital-based emergency departments were selected. First, a VGA was performed on all three layouts. A second VGA was performed after excluding unconnected spaces, and a third was performed on key patient and staff areas. Last, a fourth VGA was conducted after performing physical modifications to the three departments. Statistical analysis revealed significant differences in VGA measures not only between different layouts but also between the original and modified layouts. Specifically, small changes created by architectural features can affect visual access and exposure as measured by space syntax. Alcove-style spaces in key staff areas are also associated with limited visual control of the local environment. Typically, in smaller zones, central staff workstations afford better control of patient spaces. This study shows that space syntax analysis is a useful tool for identifying risks of aggression in hospital spaces and for identifying interventional opportunities.

Vaccine effectiveness of recombinant and standard dose influenza vaccines against outpatient illness during 2018–2019 and 2019–2020 calculated using a retrospective test-negative design

ABSTRACT Newer influenza vaccine formulations have entered the market, but real-world effectiveness studies are not widely conducted until there is sufficient uptake. We conducted a retrospective test-negative case-control study to determine relative vaccine effectiveness (rVE) of recombinant influenza vaccine or RIV4, compared with standard dose vaccines (SD) in a health system with significant RIV4 uptake. Using the electronic medical record (EMR) and the Pennsylvania state immunization registry to confirm influenza vaccination, VE against outpatient medically attended visits was calculated. Immunocompetent outpatients ages 18–64 years seen in hospital-based clinics or emergency departments who were tested for influenza using reverse transcription polymerase chain reaction (RT-PCR) assays during the 2018–2019 and 2019–2020 influenza seasons were included. Propensity scores with inverse probability weighting were used to adjust for potential confounders and determine rVE. Among this mostly white and female cohort of 5,515 individuals, 510 were vaccinated with RIV4 and 557 were vaccinated with SD, with the balance of 4,448 (81%) being unvaccinated. Adjusted influenza VE estimates were 37% overall (95% CI = 27, 46), 40% (95% CI = 25, 51) for RIV4 and 35% (95% CI = 20, 47) for standard dose vaccines. Overall, rVE of RIV4 compared to SD was not significantly higher (11%; 95% CI = −20, 33). Influenza vaccines were moderately protective against medically attended outpatient influenza during the 2018–2019 and 2019–2020 seasons. Although the point estimates are higher for RIV4, the large confidence intervals around VE estimates suggest this study was underpowered to detect significant rVE of individual vaccine formulations.

Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014.

To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time. Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time. The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities. When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.

Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative.

Public reporting of the Centers for Medicare & Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance. Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis-related QI activities for comparison based on SEP-1 performance. Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores (r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores. Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.

Trends in US Emergency Department Use After Sexual Assault, 2006-2019

Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality. To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019. This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation's Uniform Crime Reporting Program, which includes annual crime data from more than 18 000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022. Annual SA-related ED visits, subsequent hospital admissions, and associated patient-related factors (age, sex, race and ethnicity, income quartile, and insurance) were analyzed using descriptive statistics. Data were from 120 to 143 million weighted ED visits reported annually from 2006 through 2019. Sexual assault-related ED visits increased more than 1533.0% from 3607 in 2006 to 55 296 in 2019. Concurrently, admission rates for these visits declined from 12.6% to 4.3%. Female, younger, and lower-income individuals were more likely to present to the ED after SA. Older and Medicaid-insured patients were more likely to be admitted. Overall, the rate of ED visits for SA outpaced law enforcement reporting. This cross-sectional study found that US adult SA ED visits increased from 2006 through 2019 and highlighted the populations who access emergency care most frequently and who more likely need inpatient care. These data can inform policies and the programming needed to support this vulnerable population.

49 Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Departments

Significant variability exists in patient population and diagnostic capabilities of large academic tertiary, community-based hospital, and free-standing emergency departments (ED). Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based ED (HBED) settings and the translation of these protocols into the free-standing EDs (FSED) has yet to be explored. This study compared the safety, efficacy, and ED throughput of applying a 0/1-hour, rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs.

Documented Visio-Vestibular Examination and Anticipatory Guidance for Pediatric Concussion Patients.

Pediatric concussion patients are frequently managed in the primary care or acute care settings. Optimal care includes vision and vestibular assessments, as well as targeted anticipatory guidance for return to school and activity. We aimed to examine clinical practices related to the evaluation and management of concussion patients at children's hospital-based emergency department (ED) and primary care/urgent care settings. We conducted a retrospective chart review of children aged 5 to 18 years who presented to either the ED or the primary and urgent care settings during a 2-year period. We evaluated 2 concussion management practices: (1) completion of the visio-vestibular examination and (2) provision of anticipatory guidance and follow-up. Among patients seen in the ED (n = 500), only 12.4% had at least 1 component of the visio-vestibular examination performed compared with 51.3% of patients (n = 78) in the primary and urgent care settings ( P < 0.05). Regarding anticipatory guidance, 86.2% of ED patients were advised to engage in cognitive rest, and 94.2% were told to physically rest compared with 67.9% and 72.8% in the primary and urgent care settings ( P < 0.05), respectively. Follow-up recommendations were provided similarly for both settings (92.0% in the ED and 85.9% in the primary/urgent care, P = 0.077). Although most pediatric concussion patients receive instructions acutely about cognitive and physical rest, there is opportunity to increase the frequency of visio-vestibular testing in both the ED and the primary care settings. Future efforts should focus on strategies to consistently optimize visio-vestibular assessment given its value in concussion diagnosis.

Epidemiology and injectable antiseizure medication treatment patterns of seizure patients treated in United States hospitals.

ObjectiveThis study aimed to examine the epidemiology of seizures, clinical outcomes, and antiseizure medication treatment patterns among seizure patients treated in United States hospitals.DesignA retrospective cross-sectional study was conducted using data from a large geographically diverse hospital discharge database.Setting860 acute care hospitals in the United States.ParticipantsPatients aged ≥18 years with an outpatient emergency department or inpatient visit between 1 July 2016–31 December 2019 were included.InterventionNone.Main outcomes and measuresKey outcomes included prevalence of seizure, seizure type, admission point of origin, intensive care unit admission, discharge status, and injectable antiseizure medication utilization. Seizures were identified by the International Classification of Disease, Tenth Revision, Clinical Modification diagnosis codes.ResultsAmong 36,598,627 unique emergency department outpatients (72,372,464 outpatient visits) and 16,543,592 unique inpatients (24,923,489 inpatient admissions) analyzed, seizure was present in 2.1% of outpatients (1.87% of outpatient visits) and 4.9% of inpatients (4.8% of inpatient admissions). In overall seizure patients, 49.1% were unclassified, 4.4% had generalized onset, 2.9% had focal onset, and 42.8% were categorized as other (including 38.5% with convulsion). Among seizure-associated inpatient admissions, <1% were transferred directly from skilled nursing facility or other long-term care facilities but 22.7% were discharged to such facilities. Nearly a third (31%) of all inpatients were admitted to ICU. About 88.3% of patients with injectable ASM use had monotherapy, 4.6% had polytherapy with 1 day or multiple non-consecutive days of overlap, and 7.0% had polytherapy with ≥2 consecutive days of overlap. The percentage of patients with no step down to any oral ASM ranged between 34.0–57.0%.ConclusionsSeizures affect a substantial number of hospital-based emergency department outpatient and inpatient encounters and are associated with poor clinical outcomes and significant healthcare burden. Concomitant use of injectable ASMs is uncommon and a high percentage of IV ASM users with a diagnosis of seizure had no step down to oral therapy.RelevanceThe study findings may inform clinicians and hospital decision makers about current clinical practice and burden of seizures and identify areas to improve overall outcomes for patients with seizures.