Index Emergency Department Visit Research Articles

Risk-stratification tools for emergency department patients with syncope: A systematic review and meta-analysis of direct evidence for SAEM GRACE.

Approximately 10% of patients with syncope have serious or life-threatening causes that may not be apparent during the initial emergency department (ED) assessment. Consequently, researchers have developed clinical decision rules (CDRs) to predict adverse outcomes and risk stratify ED syncope patients. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the methodological quality and predictive accuracy of CDRs for developing an evidence-based ED syncope management guideline. We conducted a systematic literature search according to the patient-intervention-control-outcome question: In patients 16 years of age or older who present to the ED with syncope for whom no underlying serious/life-threatening condition was found during the index ED visit (population), are risk stratification tools (intervention), better than unstructured clinical judgment (i.e., usual care; comparison), for providing accurate prognosis and aiding disposition decision for outcomes within 30 days (outcome)? Two reviewers independently assessed articles for inclusion and methodological quality. We performed statistical analysis using Meta-DiSc. We used GRADEPro GDT software to determine the certainty of the evidence and create a summary of the findings (SoF) tables. Of 2047 publications obtained through the search strategy, 31 comprising 13 CDRs met the inclusion criteria. There were 13 derivation studies (17,578 participants) and 24 validation studies (14,845 participants). Only three CDRs were validated in more than two studies. The San Francisco Syncope Rule (SFSR) was validated in 12 studies: positive likelihood ratio (LR+) 1.15-4.70 and negative likelihood ratio (LR-) 0.03-0.64. The Canadian Syncope Risk Score (CSRS) was validated in five studies: LR+ 1.15-2.58 and LR- 0.05-0.50. The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score was validated in five studies: LR+ 1.16-3.32 and LR- 0.14-0.46. Most CDRs for ED adult syncope management have low-quality evidence for routine clinical practice use. Only three CDRs (SFSR, CSRS, OESIL) are validated by more than two studies, with significant overlap in operating characteristics.

Risk factors for acute appendicitis among adult patients with indeterminate ultrasound.

Abdominal ultrasound is used for diagnosing appendicitis in patients with right lower quadrant abdominal pain. Between 45 and 82% of radiology performed ultrasounds are indeterminate for appendicitis and computed tomography is required for diagnostic confirmation. Our study aims to determine predictors to rule out appendicitis when ultrasound is indeterminate. We performed a health records review of adult emergency department (ED) patients presenting with symptoms suspicious for appendicitis and indeterminate ultrasound to two academic EDs between June 2019 and July 2020. The outcome was appendicitis diagnosis within 30days of the index ED visit. We used multivariable logistic regression, identifying a cut-off threshold for continuous variables with cubic spline, and chose the parsimonious model to develop a binary decision rule. We report Odds ratios (OR) and diagnostic performance with 95% confidence intervals (CI). Overall, 463 patients (mean age 30.3years (SD 10.5years), 74.9% female) were included. Appendicitis was diagnosed in 45 patients (9.7% [95% CI 7.2-12.8%]). After ultrasound, computed tomography was performed in 227 patients (49.0%) and 39 patients (17.2%) were diagnosed with appendicitis. Among the 236 patients who did not have a subsequent computed tomography, 6 (2.6%) patients had appendicitis. Neutrophil count > 5.5 × 109/L (OR 1.21 [95% CI 1.12-1.30]) and secondary signs of inflammation on ultrasound (OR 2.16 [1.07-4.37]) were associated with a higher likelihood of appendicitis (C-statistic 0.77 [95% CI 0.70-0.84]). The absence of both predictors had a sensitivity of 88.9% (95% CI 76.0-96.3%), specificity of 45.7% (95% CI 40.8-50.6%) and a negative predictive value of 0.97 (95% CI 0.94-0.99) to rule out appendicitis. For patients suspected of appendicitis and indeterminate ultrasound, the absence of an elevated neutrophil count and secondary signs of inflammation are associated with a low probability of appendicitis.

Evaluation of unplanned reattendances to the pediatric emergency department – a five-year study

BackgroundUnplanned reattendances (UR) are an important quality indicator in the emergency department (ED). Understanding the risk factors associated with UR can aid clinicians in optimizing the allocation of time and resources, as well as targeted counselling for this specific group of patients. In this study, we aimed to compare patient characteristics between children who attended a pediatric emergency department (ED) with unplanned reattendances (UR) and those without UR. We also aimed to study the association between healthcare delivery factors such as timing of the attendance, patient load, changeover months for rotating junior doctors, presence of supervision, and rate of UR.Study designWe performed a retrospective, single-center cohort study of patients < 18 years old who visited the ED between January 2018 and March 2023. UR was defined as a revisit within 72 h of the index ED visit. We collected data on demographics, attendance data and clinical characteristics. Logistic regression was performed for factors independently associated with UR, after adjusting for age, patient acuity, timing of attendance, presence of senior doctor supervision, rotation months for junior doctors, and diagnostic category.ResultsOut of the 544,699 eligible children, 24,733 (4.5%) reattended the ED within 72 h, of which 10,915 (44.1%) of them were hospitalized on their reattendance visit. The independent factors associated with UR were young age (age < 3 years old: aOR 1.585 95%CI 1.481–1.698, p < 0.001), high acuity P2+ (aOR 1.398 95%CI 1.354–1.444, p < 0.001), attendance in the evening (aOR 1.086 95%CI 1.055–1.117, p < 0.001) and night (aOR 1.365 95%CI 1.314–1.417, p < 0.001), gastrointestinal diagnosis (aOR 1.528, CI 1.469–1.588; p < 0.001) and respiratory diagnosis (aOR 1.155, CI 1.121–1.189, p < 0.001).ConclusionsWe identified independent risk factors for UR that could guide resource allocation. Future studies should investigate if targeted interventions may reduce UR in these at-risk populations.

Extending emergency care beyond discharge: Piloting a virtual after care clinic.

Many unscheduled return visits to the emergency department (ED) stem from insufficient access to outpatient follow-up. We piloted an emergency medicine-staffed, on-demand, virtual after care clinic (VACC) as an alternative for discharged ED patients. Prospective cohort study of discharged ED patients who scheduled VACC appointments within 72hoursof index ED visit. We performed descriptive analyses and compared risks of ED return at 72hours and 30 days between patients who did/did not attend their appointment. From March to December 2022, 309 patients scheduled VACC appointments and 210 (68%) attended them. Patients who scheduled appointments were young (median 37 years), non-Hispanic white (80%), females (75%) with a primary care physicians (PCP) (90%), and commercial insurance (72%). Most VACC visits reinforced ED testing and/or treatment (64%) or adjusted medications (26%). VACC attendees were less likely to return to the ED within 72h (3.3%vs. 13.1%; risk difference 9.3% [95% confidence interval, CI 2.7%‒19.8%]) and 30 days (16.2%vs. 30.3%; risk difference 14.1% [95% CI 3.8%‒24.4%]) compared to those who scheduled but did not attend a VACC appointment.VACC attendance was associated with lower odds of 72-h (adjusted odds ratio [aOR] 0.0; 95% CI 0.0‒0.4) and 30-day (aOR 0.4; 95% CI 0.2‒0.7) return ED visits. In this pilot study, younger, white, female, commercially insured patients with a PCP preferentially scheduled VACC appointments. Among patients who scheduled VACC appointments, those who attended their appointments were less likely to return to the ED within 72hours and 30 days than those who did not.

Implementation of a High-sensitivity Troponin Assay for Adult Patients Who Present to the Emergency Department: The Role of Clinical Decision Support

BackgroundThe objective of this study was to assess the health outcomes for patients who present to the emergency department (ED) with cardiac chest pain after the implementation of an accelerated diagnostic protocol using a high-sensitivity troponin assay (hs-TnI). MethodsThis prospective before-after cohort study used population-based linked health administrative data for adult patients who presented to a Canadian urban ED with chest pain of suspected cardiac origin over a 2-year study period. The primary outcome was ED length of stay (LOS). Secondary outcomes included operational and clinical outcomes within 30 days of the index ED visit. ResultsDuring the study period, 4339 patients were included, with 2031 in the conventional troponin group and 2308 in the hs-TnI group. Overall, the median age was 56 years and 52% were male. The median ED LOS was reduced from 430 minutes to 400 minutes after protocol implementation (median difference, -30.0; 95% confidence interval, -47.8 to -12.3). For discharged patients who underwent serial troponin tests, the LOS was 89 minutes shorter (95% confidence interval, -110.8 to -67.2). The proportion of patients discharged increased from 73% to 78% after implementation (P = 0.0001). At 30 days, there were no differences in hospital readmission or major adverse event outcomes. ConclusionsUsing clinical decision support, the implementation of a new hs-TnI and accelerated diagnostic protocol was associated with shorter ED LOS and fewer hospitalizations for adult patients with chest pain who were assessed in the ED. These results suggest that the protocol is effective and safe in real-world clinical settings.

2322 Passing the baton from emergency visit to community care: factors that impact delivery of targeted geriatric care?

Abstract Introduction Older patients attending the Emergency Department (ED) and discharged home are at higher risk of adverse outcomes. Geriatric Ambulatory ED services were developed with the aim to deliver goal-directed care of older patients from ED using onward referral to Community Providers. Method A retrospective review was undertaken from 13th January 2022 to 23rd December 2022 in older patients discharged from the ED following a targeted geriatric assessment and recommended community follow-up interventions. Demographic information, functional ability, hospital utilisation and mortality (up to one year), and any post-visit fragility fractures were reviewed. Data collection included identification of osteoporosis or osteopenia during or following the index ED visit. Results 108 patients were assessed, of whom, 74% were female, average age 76 years, range 61–93 years. 65% of patients were CFS scored, 9% were CFS 6 or 7, 15% CFS 4 or 5 and 41% CFS 1–3. GP review was advised for 76% of patients and 61% attended and therapy interventions were recommended for 9.3%, of whom, 3% attended. The majority presented with falls (82%) and half of those who fell, sustained a fracture. Osteoporosis or osteopenia was newly identified in 30% but in 44% of patients bone health remained unevaluated and only 8% had newly initiated anti-resorptive and 9% existing treatment. 4% experienced fragility fracture following their ED visit. Uptake was low for therapy (30%) and nursing interventions (14%). Following the index ED visit, 7% patients attended ED within 7-days, and 5% admitted to hospital within 30-days. 35% of patients re-attended ED and 22% were hospitalised within one year. One year mortality was 5%. Conclusion ED targeted geriatric assessment can identify patients with falls and fragility fractures but better collaboration and communication between primary and secondary care is needed. Recommended bone health assessment occurred in a relatively small proportion of patients.

Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit

Hospitalizations related to opioid use disorder (OUD) represent an opportunity to initiate medication for OUD (MOUD). To assess whether starting MOUD after a hospitalization or emergency department (ED) visit is associated with the odds of fatal and nonfatal opioid overdose at 6 and 12 months. This population-based cohort study used data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other administrative health datasets, for individuals aged 18 years or older who had diagnosis codes related to OUD recorded at an index ED visit or hospitalization from January 2017 to December 2019. Data were analyzed between May 2023 and January 2024. Receipt of MOUD within the 7 days after an OUD-related hospital visit. The primary outcome was fatal or nonfatal overdose at 6 and 12 months after discharge. Sample characteristics, including age, sex, insurance plan, number of comorbidities, and opioid-related overdose events, were stratified by receipt or nonreceipt of MOUD within 7 days after an OUD-related hospital visit. A logistic regression model was used to investigate the association between receipt of MOUD and having an opioid overdose event. The study included 22 235 patients (53.1% female; 25.0% aged 25-39 years) who had an OUD-related hospital visit during the study period. Overall, 1184 patients (5.3%) received MOUD within 7 days of their ED visit or hospitalization. Of these patients, 683 (57.7%) received buprenorphine, 463 (39.1%) received methadone, and 46 (3.9%) received long-acting injectable naltrexone. Patients who received MOUD within 7 days after discharge had lower adjusted odds of fatal or nonfatal overdose at 6 months compared with those who did not (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.97). At 12 months, there was no difference in adjusted odds of fatal or nonfatal overdose between these groups (AOR, 0.79; 95% CI, 0.58-1.08). Patients had a lower risk of fatal or nonfatal overdose at 6 months associated with buprenorphine use (AOR, 0.50; 95% CI, 0.27-0.95) but not with methadone use (AOR, 0.57; 95% CI, 0.28-1.17). In this cohort study of individuals with an OUD-related hospital visit, initiation of MOUD was associated with reduced odds of opioid-related overdose at 6 months. Hospitals should consider implementing programs and protocols to offer initiation of MOUD to patients with OUD who present for care.

Emergency Department-Based Physical Function Measures for Falls in Older Adults and Outcomes: A Secondary Analysis of GAPcare.

Falls are the leading reason for injury-related emergency department (ED) visits for older adults. The Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), an in-ED intervention combining a medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist, reduced ED revisits at 6 months among older adults presenting after a fall. Our objective was to evaluate the relationship between measures of function obtained in the ED and clinical outcomes. This was a secondary analysis of data from GAPcare, a randomized controlled trial conducted from January 2018 to October 2019 at 2 urban academic EDs. Standardized measures of function (Timed Up and Go [TUG] test, Barthel Activity of Daily Living [ADL], Activity Measure for Post Acute Care [AM-PAC] 6 clicks) were collected at the ED index visit. We performed a descriptive analysis and hypothesis testing (chi square test and analysis of variance) to assess the relationship of functional measures with outcomes (ED disposition, ED revisits for falls, and place of residence at 6 months). Emergency department disposition status refers to discharge location immediately after the ED evaluation is complete (eg, hospital admission, original residence, skilled nursing facility). Among 110 participants, 55 were randomized to the GAPcare intervention and 55 received usual care. Of those randomized to the intervention, 46 received physical therapy consultation. Median age was 81 years; participants were predominantly women (67%) and White (94%). Seventy-three (66%) were discharged to their original residence, 14 (13%) were discharged to a skilled nursing facility and 22 (20%) were admitted. There was no difference in ED disposition status by index visit Barthel ADLs (P = .371); however, TUG times were faster (P = .016), and AM-PAC 6 clicks score was higher among participants discharged to their original residence (P ≤ .001). Participants with slower TUG times at the index ED visit were more likely to reside in nursing homes by six months (P = .002), while Barthel ADL and AM-PAC 6 clicks did not differ between those residing at home and other settings. Measures of function collected at the index ED visit, such as the AM-PAC 6 clicks and TUG time, may be helpful at predicting clinical outcomes for older adults presenting for a fall. Based on our study findings, we suggest a novel workflow to guide the use of these clinical measures for ED patients with falls.

A Comprehensive Evaluation of Emergency Department Utilization by Patients With Cirrhosis.

Emergency department (ED)-based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) vs non-HEDU in individuals with cirrhosis. We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. There were 2,124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), metabolic dysfunction-associated steatohepatitis (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits, 20% (n = 424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were model for end-stage liver disease-sodium (adjusted odds ratio [aOR] 1.044, 95% confidence interval [CI] 1.005-1.085), prior ED encounter (aOR 1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR 1.938, 95% CI 1.014-3.703). Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.

Association Between Serum Albumin and the Length of Hospital Stay Among Patients With Acute Heart Failure.

Introduction: Albumin plays a vital role in improving osmotic pressure and hemodynamics. A lower serum albumin level may cause pulmonary congestion and edema and contribute to myocardial dysfunction, diuresis resistance, and fluid retention in acute heart failure. Hypothesis: We hypothesized that AHF patients with normal serum albumin have shorter hospital stays. Methods: Using Electronic Medical Records, patients admitted from May 2020 through May 2021 aged >18, ICD-10, and positive Framingham Heart Failure Diagnostic Criteria were included. We excluded patients without albumin records and eGFRs less than 30mL/min/1.73m2. Prolonged hospitalization was defined as >8days of hospitalization. Results: During index emergency department visits, patients were symptomatic (New York Heart Association), aged median of 70years (Interquartile range (IQR) 18), 59% (n = 103) were male, predominantly White (73%, n = 128), and had a high Charleston Comorbidity index score [5, IQR (4-7)]. Nearly one-fourth (23%, n = 41) of the patients had <3.5g/dL albumin levels. The median length of hospital stay was eight days (IQR of 11). Comparing differences between lengths of hospital stays (<8 vs. >8 days), there was different serum albumin (3.9 + 0.48 vs. 3.6 + 0.53, p < .001) and left ventricular ejection fraction (45% (range 26-63) versus 30% (range 24-48), p = .004). An increased serum albumin decreased prolonged hospitalization (odds ratio (OR), 0.28; 95% confidence interval (CI), 0.14-0.55, p = <0.001). Patients in the lower albumin group had higher NT-proBNP (median: 8521 (range 2025-9134) versus 5147 (range 2966-14,795) pg/ml, p = .007) and delay in administering intravenous diuretics (391 (167-964) minutes versus 271 (range 157-533) minutes, p = .02). Conclusion: Hypoalbuminemia is strongly associated with prolonged hospitalization. Timely and effective diuretic therapy may reduce hospital stay durations, particularly with albumin supplementation.

Prediction of high-risk emergency department revisits from a machine-learning algorithm: a proof-of-concept study

BackgroundHigh-risk emergency department (ED) revisit is considered an important quality indicator that may reflect an increase in complications and medical burden. However, because of its multidimensional and highly complex nature,...

Association of hospital-based substance use supports on emergency department revisits: a retrospective cohort study in Sudbury, Canada from 2018 to 2022

BackgroundThis study compares emergency department (ED) revisits for patients receiving hospital-based substance-use support compared to those who did not receive specialized addiction services at Health Sciences North in Sudbury, Ontario, Canada.MethodsThe study is a retrospective observational study using administrative data from all patients presenting with substance use disorder (SUD) at Health Sciences North from January 1, 2018, and August 31, 2022 with ICD-10 codes from the Discharge Database (DAD) and the National Ambulatory Care Database (NACRS). There were two interventions under study: addiction medicine consult services (AMCS group), and specialized addiction medicine unit (AMU group). The AMCS is a consult service offered for patients in the ED and those who are admitted to the hospital. The AMU is a specialized inpatient medical unit designed to offer addiction support to stabilize patients that operates under a harm-reduction philosophy. The primary outcome was all cause ED revisit within 30 days of the index ED or hospital visit. The secondary outcome was all observed ED revisits in the study period. Kaplan–Meier curves were used to measure the proportion of 30-day revisits by exposure group. Odds ratios and Hazard Ratios were calculated using logistic regression models with random effects and Cox-proportional hazard model respectively.ResultsA total of 5,367 patients with 10,871 ED index visits, and 2,127 revisits between 2018 and 2022 are included in the study. 45% (2,340/5,367) of patient were not admitted to hospital. 30-day revisits were less likely among the intervention group: Addiction Medicine Consult Services (AMCS) in the ED significantly reduced the odds of revisits (OR 0.53, 95% CI 0.39–0.71, p < 0.01) and first revisits (OR 0.42, 95% CI 0.33–0.53, p < 0.01). The AMU group was associated with lower revisits odds (OR 0.80, 95% CI 0.66–0.98, p = 0.03). For every additional year of age, the odds of revisits slightly decreased (OR 0.99, 95% CI 0.98–1.00, p = 0.01) and males were found to have an increased risk compared to females (OR 1.50, 95% CI 1.35–1.67, p < 0.01).InterpretationWe observe statistically significant differences in ED revisits for patients receiving hospital-based substance-use support at Health Sciences North. Hospital-based substance-use supports could be applied to other hospitals to reduce 30-day revisits.

Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use.

The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients' receipt of recent mental health care. Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined. During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission. Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

A217 EVALUATING PREDICTIVE SCORING AND OUTCOMES OF PATIENTS DISCHARGED HOME FROM THE EMERGENCY DEPARTMENT WITH UPPER GASTROINTESTINGAL BLEEDING

Abstract Background Upper gastrointestinal bleed (UGIB) is a common emergency department (ED) presentation. The Glasgow-Blatchford Bleeding Score (GBS) is a validated tool for predicting UGIBs requiring admission for endoscopic evaluation. Utilization of GBS in Northern Ontario EDs may help risk stratify UGIB to decrease return to care. Aims This study aimed to evaluate factors and outcomes of patients discharged from the ED with suspected UGIB. Methods A total of 1,139 charts were identified with an ICD-10 ED diagnosis of gastrointestinal hemorrhage from 2016-2022. Of these, 92 charts met inclusion criteria. Patients admitted to hospital from the index ED visit, who were below the age of 18 years at the time of presentation, or with clinically suspected lower gastrointestinal hemorrhage were excluded. Patient were further grouped by place of residence if their primary address was within Thunder Bay city limits or not. Results There were 48 males (52%) with a median age of 58.7 (IQR 32.2) at presentation with UGIB to ED. The median (IQR) Charlson Comorbidity Index (CCI) and GBS were 3 (5) and 3 (6), respectively. The odds ratio for returning to the ED and being admitted for UGIB within sixty days was 4.07 times greater for patients from the region compared to Thunder Bay residents (95% CI 1.28–12.97). GBS was found to be significantly greater (p=0.048, Mann-Whitney U-Test) among seven patients who underwent emergent endoscopy from the ED and were discharged home. In univariate K-M survival analysis, the mean survival time to hospital admission at sixty days was 45 days among those with a presenting GBS score of ampersand:003E3, compared to 57 days when GBS was 3 or less (pampersand:003C0.005, log rank Mantel-Cox). After adjustment for age, sex, place of residence, and CCI, there was a 17% increase in the expected hazard for hospital admission at sixty days for each point increase in GBS (95% CI 1.03–1.34). Similarly, the expected hazard for follow-up hospital admission was 2.95 times higher (95% CI 1.11–7.85) in patients living outside Thunder Bay travelling to seek care. There were no statistically significant hazards identified between age, sex, or CCI and hospital admission (Cox proportional hazards model, p=0.001). Of patients admitted to hospital within sixty days of ED discharge (n=17), the median length of stay was five days with 56% requiring blood transfusion and 83% receiving endoscopy. Conclusions Higher GBS scores and residence outside of Thunder Bay increase the likelihood of revisit and admission to hospital for UGIB following ED discharge. Future research will aim to compare outcomes among larger urban centers. Funding Agencies NOAMA

Emergency management and asthma risk in young Medicaid-enrolled children with recurrent wheeze

Objectives To describe clinical characteristics of young children presenting to the emergency department (ED) for early recurrent wheeze, and determine factors associated with subsequent persistent wheeze and risk for early childhood asthma. Methods Retrospective cohort study of Medicaid-enrolled children 0–3 years old with an index ED visit for wheeze (e.g. bronchiolitis, reactive airway disease) from 2009 to 2013, and at least one prior documented episode of wheeze at an ED or primary care visit. The primary outcome was persistent wheeze between 4 and 6 years of age. Demographics and clinical characteristics were collected from the index ED visit. Logistic regression was used to estimate the association between potential risk factors and subsequent persistent wheeze. Results During the study period, 41,710 children presented to the ED for recurrent wheeze. Mean age was 1.3 years; 59% were male, 42% Black, and 6% Hispanic. At index ED visits, the most common diagnosis was acute bronchiolitis (40%); 77% of children received an oral corticosteroid prescription. Between 4 and 6 years of age, 11,708 (28%) children had persistent wheeze. A greater number of wheezing episodes was associated with an increased odds of ED treatment with asthma medications. Subsequent persistent wheeze was associated with male sex, Black race, atopy, prescription for bronchodilators or corticosteroids, and greater number of visits for wheeze. Conclusions Young children with persistent wheeze are at risk for childhood asthma. Thus, identification of risk factors associated with persistent wheeze in young children with recurrent wheeze might aid in early detection of asthma and initiation of preventative therapies.

Pediatric Asthma Exacerbations: 14-Day Emergency Department Return Visit Risk Factors

BackgroundAsthma, the most common chronic disease of childhood, can affect a child's physical and mental health and social and emotional development. ObjectiveThe aim of this study was to identify factors associated with emergency department (ED) return visits for asthma exacerbations within 14 days of an initial visit. MethodsThis was a retrospective review from Cerner Real-World Data for patients aged from 5 to 18 years and seen at an ED for an asthma exacerbation and discharged home at the index ED visit. Asthma visits were defined as encounters in which a patient was diagnosed with asthma and a beta agonist, anticholinergic, or systemic steroid was ordered or prescribed at that encounter. Return visits were ED visits for asthma within 14 days of an index ED visit. Data, including demographic characteristics, ED evaluation and treatment, health care utilization, and medical history, were collected. Data were analyzed via logistic regression mixed effects model. ResultsA total of 80,434 index visits and 17,443 return visits met inclusion criteria. Prior ED return visits in the past year were associated with increased odds of a return visit (odds ratio [OR] 2.12; 95% CI 2.07–2.16). History of pneumonia, a concomitant diagnosis of pneumonia, and fever were associated with increased odds of a return visit (OR 1.19; 95% CI 1.10–1.29; OR 1.15; 95% CI 1.04–1.28; OR 1.20; 95% CI 1.11–1.30, respectively). ConclusionsSeveral variables seem to be associated with statistically significant increased odds of ED return visits. These findings indicate a potentially identifiable population of at-risk patients who may benefit from additional evaluation, planning, or education prior to discharge.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments.

Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Cost of Pediatric Pneumonia Episodes With or Without Chest Radiography.

Despite its routine use, it is unclear whether chest radiograph (CXR) is a cost-effective strategy in the workup of community-acquired pneumonia (CAP) in the pediatric emergency department (ED). We sought to assess the costs of CAP episodes with and without CXR among children discharged from the ED. This was a retrospective cohort study within the Healthcare Cost and Utilization Project State ED and Inpatient Databases of children aged 3 months to 18 years with CAP discharged from any EDs in 8 states from 2014 to 2019. We evaluated total 28-day costs after ED discharge, including the index visit and subsequent care. Mixed-effects linear regression models adjusted for patient-level variables and illness severity were performed to evaluate the association between CXR and costs. We evaluated 225c781 children with CAP, and 86.2% had CXR at the index ED visit. Median costs of the 28-day episodes, index ED visits, and subsequent visits were $314 (interquartile range [IQR] 208-497), $288 (IQR 195-433), and $255 (IQR 133-637), respectively. There was a $33 (95% confidence interval [CI] 22-44) savings over 28-days per patient for those who received a CXR compared with no CXR after adjusting for patient-level variables and illness severity. Costs during subsequent visits ($26 savings, 95% CI 16-36) accounted for the majority of the savings as compared with the index ED visit ($6, 95% CI 3-10). Performance of CXR for CAP diagnosis is associated with lower costs when considering the downstream provision of care among patients who require subsequent health care after initial ED discharge.

Real-world analysis of two ischaemic stroke and TIA systolic blood pressure goals on 12-month mortality and recurrent vascular events

IntroductionWhether obtaining the more intensive goal systolic blood pressure (SBP) of <130 mm Hg, rather than a less intensive SBP goal of <140 mm Hg poststroke/transient ischaemic attack (TIA) is...

Concurrent Alcohol and Opioid Intoxication in Emergency Department Patients Leads to Greater Resource Utilization

Background: Concurrent alcohol intoxication can complicate emergency department (ED) presentations for opioid-related adverse events. We sought to determine if there was a difference in resource utilization among patients who presented to the ED with concurrent opioid and alcohol intoxication compared to opioid intoxication alone. Methods: Using linked state-wide databases from the Maryland Healthcare Cost and Utilization Project (HCUP), we identified patients with a diagnosis of opioid intoxication treated in the ED from 2016 to 2018. We measured healthcare utilization for each patient in the ED settings for one year after the initial ED visit and estimated direct costs. We performed logistic regression comparing patients presented with co-intoxication to those without. Results: Of 12,295 patients who presented to the ED for opioid intoxication during the study period, 703 (5.7%) had concurrent alcohol intoxication. Patients with co-intoxication had more recurrent ED visits (340 vs 247.4 per 1000 patients, p < 0.05), higher index ED visit admission rates (26.9% vs 19.4%, p < 0.001), but similar overall costs ($3736 vs $2861, p < 0.05) at one year. Co-intoxication was associated with suicidal ideation (OR = 1.58, 95% CI 1.51–1.65), high zip code income (OR = 1.16, 95% CI 1.12–1.21), and higher rates of intoxication with all classes of drugs analyzed (p < 0.001). Conclusion: Our study demonstrated that mental health disorders, socioeconomic status, and increased ED utilization are associated with co-intoxication of opioids and alcohol presenting to the ED. Further research is needed to elucidate factors responsible for the increased resource use in this population.