Hours Of Emergency Department Discharge Research Articles

Derivation and validation of a clinical decision rule to risk-stratify COVID-19 patients discharged from the emergency department: The CCEDRRN COVID discharge score.

To risk-stratify COVID-19 patients being considered for discharge from the emergency department (ED). We conducted an observational study to derive and validate a clinical decision rule to identify COVID-19 patients at risk for hospital admission or death within 72hours of ED discharge. We used data from 49 sites in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) between March 1, 2020, and September 8, 2021. We randomly assigned hospitals to derivation or validation and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting short-term adverse outcomes in a validation cohort. Of 15,305 eligible patient visits, 535 (3.6%) experienced the outcome. The score included age, sex, pregnancy status, temperature, arrival mode, respiratory rate, and respiratory distress. The area under the curve was 0.70 (95% confidence interval [CI] 0.68-0.73) in derivation and 0.71 (95% CI 0.68-0.73) in combined derivation and validation cohorts. Among those with a score of 3 or less, the risk for the primary outcome was 1.9% or less, and the sensitivity of using 3 as a rule-out score was 89.3% (95% CI 82.7-94.0). Among those with a score of≥9, the risk for the primary outcome was as high as 12.2% and the specificity of using 9 as a rule-in score was 95.6% (95% CI 94.9-96.2). The CCEDRRN COVID discharge score can identify patients at risk of short-term adverse outcomes after ED discharge with variables that are readily available on patient arrival.

A machine learning approach to characterize patients with asthma exacerbation attending an acute care setting

BackgroundOne of the main problems in poorly controlled asthma is the access to the Emergency Department (ED). Using a machine learning (ML) approach, the aim of our study was to identify the main predictors of severe asthma exacerbations requiring hospital admission. MethodsConsecutive patients with asthma exacerbation were screened for inclusion within 48 hours of ED discharge. A k-means clustering algorithm was implemented to evaluate a potential distinction of different phenotypes. K-Nearest Neighbor (KNN) as instance-based algorithm and Random Forest (RF) as tree-based algorithm were implemented in order to classify patients, based on the presence of at least one additional access to the ED in the previous 12 months. ResultsTo train our model, we included 260 patients (31.5% males, mean age 47.6 years). Unsupervised ML identified two groups, based on eosinophil count. A total of 86 patients with eosinophiles ≥370 cells/µL were significantly older, had a longer disease duration, more restrictions to daily activities, and lower rate of treatment compared to 174 patients with eosinophiles <370 cells/μL. In addition, they reported lower values of predicted FEV1 (64.8±12.3% vs. 83.9±17.3%) and FEV1/FVC (71.3±9.3 vs. 78.5±6.8), with a higher amount of exacerbations/year. In supervised ML, KNN achieved the best performance in identifying frequent exacerbators (AUROC: 96.7%), confirming the importance of spirometry parameters and eosinophil count, along with the number of prior exacerbations and other clinical and demographic variables. ConclusionsThis study confirms the key prognostic value of eosinophiles in asthma, suggesting the usefulness of ML in defining biological pathways that can help plan personalized pharmacological and rehabilitation strategies.

Case Report: Anisocoria (Unilateral Acute Mydriasis) After Travel on a Cruise Ship

A 32-year-old female presented to the Emergency Department (ED) with a complaint of blurred vision of a three hour duration. Her husband noted that her right pupil appeared to be dilated. However, on repeat questioning, the patient offered that she had just returned from a Caribbean cruise. She was asked about the use of a scopolamine patch. At that point, she recalled that she had removed a scopolamine patch from behind her right ear and had removed her contact lses just prior to the onset of symptoms. She noted that she had experienced some difficulty removing the contact lens of her right eye. She had removed the contact lens and the scopolamine patch with the right hand. The blurry vision began minutes later. The patient was offered confirmatory testing with pilocarpine drops, but she declined, as she felt very confident in the association of the association of the scopolamine patch with the onset of symptoms. She was discharged with follow up with ophthalmology. Her symptoms resolved fully within 24 hours of ED discharge. This case highlights the importance of recursive history taking in the event of an usual presentation.

97. Pharmacist Driven Antimicrobial Stewardship Interventions on the Management of Urinary Tract Infections in the Emergency Department at a Tertiary Military Treatment Facility

BackgroundWith the Joint Commission standards targeting ambulatory settings serving as a catalyst, we designed a quality improvement (QI) project was designed to evaluate the existing management and prescribing patterns for urinary tract infections (UTI) in the Walter Reed National Military Medical Center (WRNMMC) Emergency Department (ED) in order to identify targets for ASP intervention. MethodsThis was a Pharmacist-driven, prospective, QI project conducted over a 3-month period. The clinical presentations and microbiological data of uncomplicated cystitis and pyelonephritis cases managed in the ED were reviewed. Within 24-72 hours of ED discharge, recommendations were relayed to both patients and ED staff. Diagnostic criteria and management concordant with established clinical guidelines were assessed. Inclusion criteria included age ≥ 18, admission status, urine culture and antibiotics for UTI or pyelonephritis.ResultsA daily urinalysis (UA) report identified 1781 ED encounters of which 117 cases met inclusion criteria. Nitrofurantoin was most prescribed empirically at 39.3% followed by a cephalosporin (23.1%) or a fluoroquinolone (19.7%), accounting for 32% of inappropriate empiric antibiotic selection. Cases were identified with inappropriate duration of therapy (22.2%), dosage (9.4%), and drug-bug mismatch (9.4%). Nearly 38% of cases required intervention to discontinue (32.5%) or initiate new antibiotics (3.4%). Diagnostic concordance was defined as having positive urinary symptoms, clinically significant UA and positive urine culture. This was only observed in 37.6% of all cases, of which only 43.2% were treated with a guideline concordant empiric regimen, dosage and duration of therapy. Although not included in the final analysis, it was noted 916 urine culture results were ordered where 70% were not associated with genitourinary complaints or sepsis.ConclusionDespite guidelines for UTI management, considerable practice discordance was found in the ED. Multiple Pharmacist targeted interventions were identified. Prioritized areas for ED provider education include first-line therapy, treatment duration, and diagnostic stewardship. This QI project has potential for optimizing prescribing practices in Military Health System ambulatory settings. Disclosures All Authors: No reported disclosures

LO74: Exploring emergency physicians’ ability to predict patient admission and decrease consultation to admission time

Introduction: Delay of hospital admission until completion of assessment by consultants is a major contributor to emergency department (ED) crowding. We measured emergency physicians’ (EP) ability to predict patient admission, and estimated potential time saved if EPs could request a bed at the time of consultation. Methods: This is a prospective cohort study in a tertiary care center over 4 months using a convenience sample of ED patients requiring consultation. We consecutively recruited patients from purposefully selected shifts to balance day of the week and time of day. We excluded patients younger than 18 years or those likely to be admitted (traumas, strokes, STEMI codes, and CTAS1). We asked EPs to predict patient disposition (admission or alternate disposition) just before consultation. We defined admission as: admission to any service, admission within 48 hours of ED discharge, patients held overnight without bed request, or if bed request was delayed by 12 or more hours, and alternate disposition as any other disposition. We present EP prediction test characteristics using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI). The potential time saved was calculated from consultation to bed request for admitted patients. Results: Characteristics for the 454 included patients were: mean age 60.1 years, 48.4% male, 46.9% evening presentation, 69.4% were admitted (most commonly by Internal Medicine 26.9%), and median consult to bed request time was 3.5 hours (interquartile range 2.0 – 5.3 hours). Overall EP prediction sensitivity, specificity, PPV and NPV were 90.5% (95%CI 86.7-93.5), 84.2% (95%CI 77.0-89.8), 92.8% (95%CI 89.8-95.0) and 79.6% (95%CI 73.4-84.7) respectively. In other words, EPs correctly predicted 92.8% of patient admissions. The PPV for Internal Medicine was 95.7% (95%CI 89.7-98.4) and ranged from 78.9% (95%CI 53.9-93.0) for Psychiatry to 100% (95%CI 78.1-100) for Family Medicine. A total of 1113.5 hours of ED stretcher time (37.1 hours per shift) could have been saved if EPs initiated a concurrent bed request at time of consultation. Conclusion: EPs correctly predicted 92.8% of patient admissions across a broad field of disciplines. We estimate 1113.5 hours of ED stretcher time could have been saved over the study period if EPs triggered an inpatient bed request at the time of consultation, rather than waiting for the consultants’ disposition decision.

Abstract TP280: Triage and Outpatient Evaluation of Emergency Department Patients With TIA and Minor Stroke: Rapid Access Vascular Evaluation-Neurology (RAVEN)

Introduction: The timely evaluation of TIA and minor stroke (TIAMS) is important, but whether TIAMS patients with no debilitating deficits should be admitted or not remains unsettled. We piloted a clinical protocol to assess the feasibility and safety of discharging selected TIAMS patients without disabling deficits from the Emergency Department (ED) to a rapid outpatient stroke clinic: Rapid Access Vascular Evaluation-Neurology (RAVEN). Methods: RAVEN was created as a specialized outpatient neurology clinic for TIAMS patients discharged within 24 hours from the ED at an urban quaternary academic medical center. Patients were first screened in the ED by a neurologist and selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g. National Institute of Health Stroke Scale of 5 or less, no disabling deficit, no fluctuating or recurrent symptoms over past month, no thrombolytic agent given, negative CT for hemorrhagic stroke, no new onset atrial fibrillation, blood pressure not over 180/110), as well as social criteria (e.g. patient ability to follow-up within 24 hours). Doppler ultrasound to exclude intracranial and extracranial stenosis, along with neurology re-evaluation was performed as part of RAVEN follow-up. Sample population was evaluated for rates of noncompliance with post-ED follow-up and need for hospitalization from clinic. Final diagnosis was also tabulated. Results: Between December 2016 and June 2018, 162 TIAMS patients seen in the ED were recommended for RAVEN utilizing the decision tool. Of these patients, 153 (94.4%) were evaluated within 24 hours of ED discharge. Two patients (1.3%) who received outpatient evaluation required hospitalization; 101 (66%) of these patients had a final diagnosis of TIAMS. Other common diagnoses included peripheral neuropathy (15%), migraine (12.5%) and seizure/recrudescence (4%). Conclusions: Our pilot data suggests that for a subset of TIAMS patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may improve TIAMS outcomes, reduce ED and inpatient crowding, and offer reductions in healthcare costs associated with TIAMS care.

A Randomized Trial of a Long-Acting Depot Corticosteroid Versus Dexamethasone to Prevent Headache Recurrence Among Patients With Acute Migraine Who Are Discharged From an Emergency Department

Migraine patients continue to report headache during the days and weeks after emergency department (ED) discharge. Dexamethasone is an evidence-based treatment of acute migraine that decreases the frequency of moderate or severe headache within 72 hours of ED discharge. We hypothesize that intramuscular methylprednisolone acetate, a long-acting steroid that remains biologically active for 14 days, will decrease the number of days with headache during the week after ED discharge by at least 1 day compared with intramuscular dexamethasone. We conducted a randomized, blinded clinical trial comparing intravenous metoclopramide at 10 mg+intramuscular dexamethasone at 10 mg with intravenous metoclopramide at 10 mg+intramuscular methylprednisolone acetate at a dose of 160 mg for patients presenting to 2 different EDs with moderate or severe migraine. Outcomes were assessed by telephone with astandardized instrument. The primary outcome was number of days with headache during the week after ED discharge. Secondary outcomes were complete freedom from headache, without the necessity of additional headache medication for the entire week after ED discharge, and medication preference, as determined by asking the patient whether he or she would want to receive the same medication again. One hundred nine patients received dexamethasone and 111 received methylprednisolone acetate. We obtained primary outcome data from 101 dexamethasone patients and 106 methylprednisolone acetate patients. Dexamethasone patients reported 3.0 headache days and methylprednisolone acetate 3.3 headache days (95% confidence interval for rounded mean difference of 0.4days: -0.4 to 1.1). Of 107 dexamethasone patients with analyzable data, 10 (9%) reported complete freedom from headache at 1 week versus 6 of 110 (5%) methylprednisolone acetate patients (95% confidence interval for difference of 4%: -3% to 11%). In the dexamethasone group, 76 of 101 (75%) patients would want the same medication again versus 75 of 106 (71%) of methylprednisolone acetate patients (95% confidence interval for difference of 4%: -8% to 17%). Other than injection site reactions, which were more common in the methylprednisolone acetate group, there were no substantial differences in frequency of adverse events. Methylprednisolone acetate does not decrease the frequency of post-ED discharge headache days compared withdexamethasone. Most migraine patients are likely to continue to experience headache during the week after ED discharge.

2481 A collaborative neurology-emergency medicine rapid outpatient clinic for the management of TIA and minor stroke in the emergency department

OBJECTIVES/SPECIFIC AIMS: Current practice frequently dictates hospitalization for TIA and minor stroke (TIAMS) in order to obtain comprehensive evaluation of stroke risk factors and mechanism. Inpatient hospitalization is often done to expedite workup and to coordinate care although may be associated with nosocomial risks and increased healthcare cost. However, a subset of these patients who do not have debilitating deficits may not require inpatient hospitalization. We conducted a pilot study to assess the feasibility of conducting rapid outpatient stroke evaluations in low risk patients with TIAMS without disabling deficits. METHODS/STUDY POPULATION: The rapid access clinic was initiated at a single-site urban tertiary care facility for outpatient evaluation of TIAMS within 24 hours of emergency department (ED) evaluation. Patients were selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g., no disabling deficit, no thrombolytic agent given, negative CT for hemorrhagic stroke) as well as social criteria (e.g., patient ability to follow-up as an outpatient). We evaluated rates of noncompliance with post-ED follow-up, need for hospitalization from clinic, and 90 day stroke and health outcome data. RESULTS/ANTICIPATED RESULTS: Between December 2016 and December 2017 a total of 93 TIAMS patients seen in the ED were recommended for the rapid access clinic utilizing the decision tool. Of these patients, 94.5% (86) were evaluated within 24 hours of ED discharge. Only 2 patients (2.4%) who received outpatient evaluation required hospitalization; 61 (71.8%) patients had TIAMS on final evaluation in clinic. DISCUSSION/SIGNIFICANCE OF IMPACT: Our pilot data suggests that for a subset of patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may help improve TIAMS outcomes and reduce ED crowding and unnecessary hospital admissions.

LO68: Patterns and predictors of emergency physician productivity

Introduction: Emergency Physician (EP) performance comprises both quality of care and quantity of patients seen in a set time. Emergency Department (ED) overcrowding increases the importance of the ability of EPs to see patients as rapidly as is safely possible. Maximizing efficiency requires an understanding of variables that are associated with individual physician performance. While using the incidence of return visits within 48 hours as a quality measure is controversial, repeat visits do consume ED resources. Methods: We analysed the practice variables of 85 EPs working at a single academic ED, for the period from June 1, 2013 to May 31, 2017, using data from an emergency department information system (EDIS). Variables analysed included: number of shifts worked, number of patients seen per hour (pt/hr), an adjusted workload measurement (assigning a higher score to CTAS 1-3 patients), percentage of patients whose care involved an ED learner, and the percentage of patients who returned to the ED within 48 hours of ED discharge. Resource utilization was measured by percentage of diagnostic imaging (ultra sound (US), CT scan (CT), x-ray (XR)) ordered and percentage of patients referred to consulting services. We performed principal component analyses to identify bench marks of resource use, demographic (age, EM qualification, gender) and other practice related predictors of performances. Results: Mean pt/hr differed significantly by EM Qualification for CTAS 2-4, with 1.71/hr (95% Confidence Interval=1.63-1.77) by FRCPS physicians, compared to 1.89/hr by CCFP(EM) (CI=1.81-1.97). There were no differences for CTAS 1 and 5. Other variables associated with a significantly lower pt/hr, included a greater use of imaging, (CT: p=0.0003, XR: p=0.0008) although this was did not reach statistical significance with US (p=0.06%). Female gender, older age, number of patient consultations for CTAS 3 and more patients seen by a learner were all associated with lower pt/hr. Pt/hr was a better predictor (R2=45%) for EP resource utilization than adjusted workload measurement (R2 =35%). Higher use of CT was associated with fewer return visits in &lt;48 hrs (0.13% lower). Male gender, younger age, number of patient consultation for CTAS 3 and fewer patients seen by a learner were all associated with an increase in return visits. Conclusion: We found a significant difference in pt/hr rates and return visits within 48 hours between EPs with different age ranges, gender, and EM certification. Increased use of CT scan and x-ray, and consultation for patients CTAS 3 were associated with lower pt/hr. Return visit rates also varied in association with diagnostic imagine use, age, gender and number of patients seen by a learner. Further research is needed to assess the association with these variables on quality of care.

Impact of a Stewardship Initiative to Decrease Treatment of Asymptomatic Bacteriuria and Pyuria in the Emergency Department

BackgroundAntibiotic treatment of asymptomatic bacteriuria (AB) provides no benefit and can lead to negative outcomes. The impact of asymptomatic pyuria (AP) on antibiotic use is not well characterized, nor is the impact of treating AB/AP in the emergency department (ED). The purpose of this study was to determine whether a multi-faceted stewardship initiative decreased unnecessary antibiotic treatment of AB/AP in the ED of an 885-bed academic medical center.MethodsBeginning in Dec 2015, a series of interventions were implemented, including inservices, pocket cards, electronic order entry alerts, and elimination of reflex urine cultures for abnormal urinalyses. Patients discharged from the ED in Aug-Oct 2015 (pre-intervention group) and Dec 2016-Feb 2017 (post-intervention group) were consecutively screened retrospectively. Asymptomatic patients ≥18 yrs old with ≥105 CFU/mL organisms on urine culture or >12 WBC/hpf on urinalysis were included. Patients with pregnancy, separate infection requiring antibiotics, immunocompromised state, paraplegia, neurogenic bladder, or altered genitourinary anatomy were excluded. The primary outcome was the proportion of patients with AB and/or AP prescribed antibiotics within 72 hours of ED discharge. Secondary outcomes were the number of urine cultures ordered in the ED and the number of patients returning to the ED with symptomatic urinary tract infection (UTI) within 30 days. 32 patients in each group were required to achieve 80% power, assuming 30% difference in primary outcome.Results74 patients met study criteria (37 in each group). 52 patients (70%) had AP without AB. Antibiotic treatment and the number of urine cultures ordered decreased significantly in the post group. Outcome Pre Post P Value Patients treated for AB and/or AP37/37 (100%)12/27 (32%)<0.001Patients treated for AP without AB25/25 (100%)6/27 (22%)<0.001Urine cultures ordered per 1,000 ED discharges66.337.90.004Patients returning to ED within 30 days3/374/37NSConclusionA multi-faceted stewardship initiative significantly decreased treatment of AB/AP in the ED. AP appears to contribute significantly to unnecessary antibiotic use in the ED and would be a valid target for stewardship initiatives.Disclosures All authors: No reported disclosures.

Emergency Department Return Visits Resulting in Admission: Do They Reflect Quality of Care?

Prior studies have suggested that emergency department (ED) return visits resulting in admission may be a more robust quality indicator than all 72-hour returns. The objective was to evaluate factors that contribute to admission within 72 hours of ED discharge. Each return visit resulting in admission was independently reviewed by 3 physicians. Analysis was by descriptive statistics. Of 45 071 ED discharges, 4.1% returned within 72 hours; 0.96% returned for related reasons and were admitted to wards (91.2%), intensive care units (6.5%), or operating rooms (1.2%). Management was acceptable in 92.6%, suboptimal in 7.4%. Admissions were illness (94.9%), patient (1.6%), and physician related (3.5%). Almost all admissions within 72 hours after ED discharge are illness related, including all intensive care unit admissions and the majority of operating room admissions. Deficiencies in ED care are rarely the reason for admission on return. ED return visits resulting in admission may not be reflective of ED quality of care.

LO039: The effect of desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis

Introduction: Bronchiolitis is the most common lower respiratory tract infection among infants, characterized by wheeze and respiratory distress. Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay and escalation of care. The objectives were to determine if there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who desaturate to &lt;90% for at least one minute during home oximetry monitoring versus those without desaturations. Methods: This is a prospective cohort study from 2008 to 2013 enrolling 118 otherwise healthy infant aged 6 weeks to 12 months discharged home from a tertiary care pediatric emergency department with a diagnosis of acute bronchiolitis. The primary outcome was unscheduled medical visits for bronchiolitis, a visit to any health care provider due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge and the effect of activity on desaturations. Results: During a mean monitoring period of 19 hours, 75/118 (64%) infants had at least one desaturation event (median continuous duration 3.4 minutes). 59/118 infants (50%) had at least 3 desaturations, 12 (10%) desaturated for &gt;10% monitored time and 51(43%) had desaturations lasting ≥ 3 minutes continuously. 59/118 (50%) infants desaturated to ≤ 80% and 29 (24%) to ≤ 70% for ≥ 1 minute. A total 18/75 infants with desaturations (24.0%) had an unscheduled visit for bronchiolitis versus 11/43 of their non-desaturating counterparts (25.6%) [Difference - 1.6%; 95%CI -0.15 to ∞, p=0.66]. One of 75 desaturating infants (1.3%) and 2/43 (4.6%) of those without desaturations were hospitalized within 72 hours [Difference of -3.3%; 95% CI -0.04 to 0.10, p = 0.27]. Seventy seven percent of infants with desaturations experienced them during sleep or while feeding. Conclusion: The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.

Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.

Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay, and escalation of care. To examine whether there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who have oxygen desaturations to lower than 90% for at least 1 minute during home oximetry monitoring vs those without desaturations. Prospective cohort study conducted from February 6, 2008, to April 30, 2013, at a tertiary care pediatric emergency department in Toronto, Ontario, Canada, among 118 otherwise healthy infants aged 6 weeks to 12 months discharged home from the emergency department with a diagnosis of acute bronchiolitis. The primary outcome was unscheduled medical visits for bronchiolitis, including a visit to any health care professional due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge, and the effect of activity on desaturations. A total of 118 infants were included (mean [SD] age, 4.5 [2.1] months; 69 male [58%]). During a mean (SD) monitoring period of 19 hours 57 minutes (10 hours 37 minutes), 75 of 118 infants (64%) had at least 1 desaturation event (median continuous duration, 3 minutes 22 seconds; interquartile range, 1 minute 54 seconds to 8 minutes 50 seconds). Among the 118 infants, 59 (50%) had at least 3 desaturations, 12 (10%) had desaturation for more than 10% of the monitored time, and 51 (43%) had desaturations lasting 3 or more minutes continuously. Of the 75 infants who had desaturations, 59 (79%) had desaturation to 80% or less for at least 1 minute and 29 (39%) had desaturation to 70% or less for at least 1 minute. Of the 75 infants with desaturations, 18 (24%) had an unscheduled visit for bronchiolitis as compared with 11 of the 43 infants without desaturation (26%) (difference, -1.6%; 95% CI, -0.15 to ∞; P = .66). One of the 75 infants with desaturations (1%) and 2 of the 43 infants without desaturations (5%) were hospitalized within 72 hours (difference, -3.3%; 95% CI, -0.04 to 0.10; P = .27). Among the 62 infants with desaturations who had diary information, 48 (77%) experienced them during sleep or while feeding. The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.

A Prospective Evaluation of Shared Decision-making Regarding Analgesics Selection for Older Emergency Department Patients With Acute Musculoskeletal Pain.

Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants' desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35%), received care from a nurse practitioner versus a resident or an attending physician (32% vs. 9%; difference 23%, 95% CI = 4% to 42%), or received care from a female versus a male provider (24% vs. 5%; difference 19%, 95% = CI 5% to 32%). After potential confounders were adjusted for, the mean decrease in pain severity from the ED visit to 1-week follow-up was not significantly different across tertiles of SDM (p = 0.06). Higher SDM scores were associated with greater satisfaction with the discharge pain medications (p = 0.006). SDM was not associated with the class of analgesic received. In this sample of older adults with acute musculoskeletal pain, the reported desire of patients to contribute to decisions regarding analgesics varied based on both patient and provider characteristics. SDM was not significantly related to pain reduction in the first week or type of pain medication received, but was associated with greater patient satisfaction.

Improving Adolescent Pelvic Inflammatory Disease Follow-up From the Emergency Department: Randomized Controlled Trial With Text Messages

Centers for Disease Control and Prevention guidelines recommend follow-up within 72 hours of diagnosis of pelvic inflammatory disease because patients with inadequate treatment are at increased risk of acute and chronic complications. Follow-up rates in adolescents after diagnosis range between 10% and 16%. The primary objective is to assess the effect of text message reminders to adolescent patients receiving a diagnosis of pelvic inflammatory disease on obtaining follow-up care within 72 hours of emergency department (ED) discharge. This was a single-blinded randomized controlled trial of adolescents receiving a diagnosis of pelvic inflammatory disease in the ED. Patients received standard discharge instructions or standard discharge instructions plus text message reminders. Patients in the text message group received daily, tailored text messages for 4 days, with a reminder to schedule and attend primary care provider follow-up. The primary outcome was follow-up within 72 hours of ED discharge. Ninety-five patients (48 standard; 47 text message) were randomized. Three patients were excluded, leaving 92 patients (46 standard; 46 text message) for analysis. Baseline characteristics were similar between treatment groups. Follow-up was 15.2% in the standard group and 43.5% in the text message group. Patients receiving text message reminders were more likely to follow up compared with the standard group (relative risk 2.9; 95% confidence interval [CI] 1.4 to 5.7). The absolute efficacy difference was 28.3% (95% CI 9.5% to 46.9%), yielding number needed to treat of 4 (95% CI 2.2 to 9.5). Personalized text message reminders were efficacious in improving follow-up for adolescents after ED diagnosis of pelvic inflammatory disease.

Characteristics and Risk Factors of Out-of-Hospital Cardiac Arrest Within 72 Hours After Discharge

ObjectiveTo determine the characteristics and risk factors for patients who developed out-of-hospital cardiac arrest (OHCA) within 72 hours after emergency department (ED) discharge. MethodsA nested case-control study (1:4 ratio) was conducted in 5 EDs from January 2002 to December 2011. The study group consisted of adults experiencing nontraumatic OHCA who revisited ED within 72 hours after discharge. Patients matched in sex, age group and chief complaints were selected for the control group. Demographic data, discharge diagnosis, discharge vital signs and laboratory result were collected. Etiologies of cardiac arrest and whether the events were expected or related to the 1st ED visit were reviewed. ResultsIn all, 1,657,870 patients were discharged during the study period; 109 developed OHCA within 72 hours of ED discharge (6.6/100,000 per year). The mean age was 64.7 years and 67.9% were men. After comparison with the control group, a higher heart rate (88.5± versus 81.7± beat per minutes, P = 0.003) and higher serum creatinine level (2.2± versus 1.4± mg/dL, P = 0.002) remain the statistical significant characteristics of study group by conditional logistic regression. Approximately 60% events were expected or unrelated to the 1st ED visit. Among patients whose OHCA were unexpected and related to the 1st ED visit, 71.4% had a cardiac cause. Of these, 20% had chest pain, but 40% had angina-equivalent symptoms during 1st presentation. ConclusionsA higher discharge heart rate and higher creatinine level are risk factors in these patients.

Characteristics of patients who made a return visit within 72 hours to the emergency department of a Singapore tertiary hospital.

72-hour emergency department (ED) reattendance is a widely-used quality indicator for quality of care and patient safety. It is generally assumed that patients who return within 72 hours of ED discharge (72-hour re-attendees) received inadequate treatment or evaluation. The current literature also suggests considerable variation in probable causes of 72-hour ED reattendances internationally. This study aimed to understand the characteristics of these patients at the ED of a Singapore tertiary hospital. We conducted a retrospective cohort study on all ED visits between 1 January 2013 and 31 December 2013. 72-hour re-attendees were compared against non-re-attendees based on patient demographics, mode of arrival, patient acuity category status (i.e. P1/P2/P3/P4), seniority ranking of doctor-in-charge and medical diagnoses. Multivariate analysis using the generalised linear model was conducted on variables associated with 72-hour ED re-attendance. Among 104,751 unique patients, 3,065 (2.93%) were in the 72-hour re-attendees group. Multivariate analysis showed that the following risk factors were associated with higher risk of returning within 72 hours: male gender, older age, arrival by ambulance, triaged as P2, diagnoses of heart problems, abdominal pain or viral infection (all p < 0.001), and Chinese ethnicity (p = 0.006). There was no significant difference in the seniority ranking of the doctor-in-charge between both groups (p = 0.419). Several patient and event factors were associated with higher risk of being a 72-hour re-attendee. This study forms the basis for hypothesis generation and further studies to explore reasons behind reattendances so that interventions can be developed to target high-risk groups.

Unscheduled Return Visits to the Emergency Department

Return visits to the emergency department (ED) resulting in admission are an important marker of quality of care. Patients and families with limited English proficiency (LEP) are at risk for suboptimal care related to imprecise communication. The objective of this study was to compare the rate of return visits resulting in admission in LEP patients to the rate in the English-speaking patients. We assembled a retrospective cohort of patients cared for in a pediatric, tertiary ED. Eligible patients included those who were discharged on the first encounter, and those who returned and were admitted to the hospital within 72 hours of ED discharge were identified. A logistic regression was performed comparing the rate of return visits resulting in admission in the LEP and non-LEP populations adjusting for emergency severity index and time of day at ED visit. A total of 119,782 patients were discharged from the ED during a 32-month study period. Of these patients, 11.7% (14,053) identified a language other than English as their primary language. The rate of return visits resulting in admission was 1.2% (1279/105,729) among English speakers and 1.6% (220/14,053) in the LEP population. Patients with LEP were more likely to return to the ED for admission (odds ratio, 1.30; 95% confidence interval, 1.12-1.50; P < 0.001) The increased risk of a return visit for LEP patients remained significant after controlling for age, emergency severity index, and time of day (adjusted odds ratio, 1.43; 95% confidence interval, 1.23-1.66; P < 0.001). Patients with LEP are at higher risk of return visit for admission.

Implementation of FilmArray Respiratory Viral Panel in a Core Laboratory Improves Testing Turnaround Time and Patient Care

The FilmArray respiratory virus panel detects 15 viral agents in respiratory specimens using polymerase chain reaction. We performed FilmArray respiratory viral testing in a core laboratory at a regional children’s hospital that provides service 24 hours a day 7 days a week. The average and median turnaround time were 1.6 and 1.4 hours, respectively, in contrast to 7 and 6.5 hours documented 1 year previously at an on-site reference laboratory using a direct fluorescence assay (DFA) that detected 8 viral agents. During the study period, rhinovirus was detected in 20% and coronavirus in 6% of samples using FilmArray; these viruses would not have been detected with DFA. We followed 97 patients with influenza A or influenza B who received care at the emergency department (ED). Overall, 79 patients (81%) were given oseltamivir in a timely manner defined as receiving the drug in the ED, a prescription in the ED, or a prescription within 3 hours of ED discharge. Our results demonstrate that molecular technology can be successfully deployed in a nonspecialty, high-volume, multidisciplinary core laboratory.

Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest?

Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes. This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses. The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%). Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.