Index Emergency Department Research Articles

Does N-Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope?

Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. To evaluate whether adding N-terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). Prospective cohort study. 6 EDs in 2 Canadian provinces. 1452 adult ED patients with syncope. Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P= 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.

Emergency department revisits: a nation-wide database analysis on the same and different hospital revisits.

Emergency department (ED) revisits had traditionally been used as a quality indicator, but focused more on the same hospital revisit (SHRV). Our study investigated the 72-hour ED revisits on SHRV and different hospital revisits (DHRV), and explored the predictors of DHRV. 72-hour ED revisits were analyzed using Taiwan's National Health Insurance Research Database that contained one-third patient records from 2012 to 2013. Rates of SHRV and DHRV were calculated and compared among levels of hospital accreditation. Linear regression analyses were used to measure the correlation between revisit rates and average monthly volumes of the index ED. Multilevel logistic analyses were performed to evaluate the predictors of DHRV. There were 4 065 215 index ED visits. Of them, 234 826 (5.8%) were associated with 72-hour revisits and 36.7% of them occurred at different institutions. The revisit rates showed differences across distinct hospital levels. DHRV rates had significant inverse correlation with the average monthly volume of the index ED. Independent predictors associated with the increased odds of DHRV were: ED visits on weekend or holiday, or the index ED being at a local hospital. About one in three ED revisits occurred in another hospital. SHRV rate alone would inevitably underestimate the true revisit rate. DHRV is associated with the hospital level and annual ED volume, and there is increased likelihood of DHRV if patient's index ED visit being a local hospital.

Multicenter Emergency Department Validation of the Canadian Syncope Risk Score

The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use. To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation. This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018. Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated. A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively. The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.

Resource utilization across the continuum of HIV care: An emergency department-based cohort study.

The objective of this study was to determine the healthcare resource utilization for people living with HIV (PLWH) presenting to the emergency department (ED) across the HIV Care Continuum. This prospective study enrolled PLWH presenting to an urban ED between June 2016 and March 2017. Subjects were categorized as being linked to care, retained in care, on antiretroviral therapy (ART), and virally suppressed (<200 copies/ml). Data on ED visit rates, duration of stay, and hospital admission rates were compared to local metrics. Overall, 94.3% of 159 enrollees had been linked to care, 75.5% retained in care, 81.1% on ART, and 62.8% virally suppressed. Compared to the general population of the city and of the ED, participants had a higher ED visit rate (3.0 v. 1.2 visits per person-per year) in the past two years, a higher median duration of ED stay (12.6 v. 7.6h), and a higher hospital admission rate (36.5% v. 24.9%) during their index ED visit. Viral suppression was negatively associated with admission (OR=0.35, 95% CI: 0.17, 0.72). Forty-eight (30.2%) participants who had at least eight ED visits in the past two years were more likely to have a diagnosed mental health disorder (79.2% v. 62.2%, p=0.036). Our results showed that PLWH use more ED resources than the general population and a better engagement in HIV care is linked to lesser ED resource utilization for PLWH, indicating the importance of improved HIV care engagement in healthcare utilization management.

Factors Associated with Family Physician Follow-up 30 Days Post-discharge from a Local Canadian Community Emergency Department.

IntroductionClose outpatient follow-up with a specialist or family physician post-discharge from the emergency department (ED) has been shown to increase adherence to antihypertensive medications, decrease mortality in heart failure, and reduce the odds of myocardial infarction or death after ED presentation for chest pain. A Canadian study demonstrated that 21% of patients who left the ED with a new diagnosis of atrial fibrillation, heart failure, or hypertension were not seen by a physician within 30 days. There is a paucity of research investigating why this follow-up does not occur. This study aimed to elucidate factors that are associated with outpatient follow-up by a family physician clinic following discharge from a local Canadian community emergency department.MethodsA retrospective chart review of patients rostered to a family physician who presented to the community ED in the past two years was conducted. The primary outcome examined was a documented follow-up visit with any physician at the clinic within 30 days of the index ED visit. Patients aged 18 or older at the time of the initial ED visit were eligible for inclusion in the study. Exclusion criteria were the following: patients aged 17 or younger at the time of the initial ED visit, those who were not fully assessed at ED visit (i.e., left against medical advice), those whose charts corresponding to the ED visit were unable to be found, patients who were admitted to any facility within 30 days of ED visit, and patients who died within 30 days of the ED visit. Variables of interest extracted from the ED chart and clinic electronic medical record were the following: Canadian Triage and Acuity Scale (CTAS) score, documented discharge instructions, age, sex, primary residence distance from the clinic, last documented clinic visit before ED visit, and the date of and presenting complaint of the next clinic visit after the ED visit. Data were collected as continuous and categorical variables. Descriptive statistics were used to show the number and percentages of patients who followed up in clinic. Binomial regression analysis was used to determine if a specific variable was associated with patient follow-up. Inter-rater reliability between data abstractors was calculated using Fleiss Κ. An alpha-value of 0.05 was chosen, and SPSS version 25.0 (IBM Corp., Armonk, NY) was used for all statistical analyses.ResultsA total of 234 patients out of 1292 patients met inclusion criteria. 53% of patients were female, and the mean age was 50. Seventy-two (31%) received discharge instructions from the ED physician to follow up with their family doctor. In total, 93 of the 234 patients proceeded to have a documented clinic visit within 30 days (40%). 52% (n = 48) of these were women. Receiving specific discharge instructions increased the adjusted odds of follow-up (OR 3.07, 95% CI: 1.64-5.76; P < 0.05). Patients who followed up also tended to have been seen in clinic in the last three months, but this was not statistically significant.ConclusionReceiving specific discharge instructions to follow-up increased the odds that patients followed up with their family physician after discharge from the ED. ED physicians may consider giving explicit instructions to patients to improve monitoring of ongoing clinical issues. More research needs to be conducted on how to improve transitions of care. Countries with different healthcare models may have other barriers to appropriate follow-up.

Identification of emergency department patients for referral to rapid-access addiction services.

Substance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED. This prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available. We received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated "Yes" for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period. At least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study.

Emergency department (ED) visits among older adults are frequently instigated by a fall at home. Some of these patients develop intracranial bleeding. The aim of this study was to identify the incidence of intracranial bleeding and the associated clinical features in older adults who present to the ED after falling. Prospective cohort study. Three Canadian EDs. A total of 2 176 patients age 65 years or older who presented to the ED with a fall were assessed, and 1753 were included. Inclusion criteria were a fall on level ground, off a bed, chair, or toilet, or from one or two steps within 48 hours. Emergency physicians recorded predefined clinical findings on initial assessment. The primary outcome was intracranial bleeding, diagnosed either by computed tomography at the index visit or within 42 days. Associations between baseline clinical findings and the presence of intracranial bleeding were assessed with multivariable logistic regression. A total of 1753 patients (median age = 82 y) were enrolled, of whom 39% were male, 35% were on antiplatelet therapy, and 25% were on an anticoagulant. The incidence of intracranial bleeding was 5.0% (95% confidence interval [CI] = 4.1-6.1). Overall, 76 patients were diagnosed at the index ED visit, and 12 were diagnosed during follow-up. Multivariable regression identified four clinical variables that were independently associated with intracranial bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4). The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between intracranial bleeding and antiplatelet or anticoagulant use. J Am Geriatr Soc 68:970-976, 2020.

Abstract WMP91: Head CT at Emergency Department Treat-and-Release Visit for Headache is Associated With Increased Risk of Subsequent Hospitalization for Cerebrovascular Disease

Background: Headache is a common presenting symptom among patients with misdiagnosed cerebrovascular (CVD) disease. Recent studies report that the occurrence of a head CT (HCT) during emergency department (ED) visit for non-specific neurological symptoms, such as vertigo, is associated with increased risk of stroke after ED discharge. We sought to evaluate whether the occurrence of HCT at ED visit for headache is associated with increased CVD risk. Hypothesis: Patients with headache complaints who have a HCT performed in the ED (exposed) are more likely to have a CVD admission within 365 days of ED discharge than those who do not receive a HCT (unexposed). Methods: We conducted a retrospective study of consecutive adult patients with headache complaints discharged to home (treat-and-release visit) from all four of the EDs affiliated with a single academic institution. Patients with headache complaints were defined as those with primary ICD-9/10-CM discharge diagnosis of benign headache; patients were included in our study at their first ED treat-and-release visit from 2013 to 2018. Subsequent CVD hospitalizations were identified using ICD-9/10-CM inpatient discharge codes and confirmed via chart review. We matched exposed to unexposed patients in a one-to-one fashion using propensity score methods. Standard descriptive statistics and relative risk (RR) with 95% CIs are reported. Results: Among 28,121 patients with an ED treat-and-release visit for headache complaints, 45.6% (n=12,812) underwent HCT during ED visit. A total of 0.4% (n=112) patients had a subsequent CVD admission within 365 days of ED visit. Using propensity score matching, 80.3% (n=10,295) of patients with HCT (exposed) were able to be matched. In the matched sample, exposed patients had a nearly two-fold increased relative risk of CVD at 365 days (RR: 1.83; 95% CI: 1.12-3.01). In secondary analysis, CVD risk at 180 days was also higher in exposed (RR: 2.06; 95% CI: 1.13-3.74). Conclusion: Having a HCT performed at index ED treat-and-release visit among those with headache complaints establishes a clinically meaningful risk gradient for subsequent CVD hospitalization. Some ED patients given a headache diagnosis may have been misdiagnosed at index visit.

Diagnostic yield of pulmonary embolism testing in patients presenting to the emergency department with syncope

BackgroundSyncope occurs in 1 in 4 people during their lifetime and accounts for 1% to 1.5% of emergency department (ED) visits. Most causes of syncope are benign, but syncope may be caused by life‐threatening conditions including pulmonary embolism (PE) in up to 2% of cases. A recent publication reported the prevalence of PE in patients with syncope to be over 17%. AimsWe sought to determine the frequency and diagnostic yield of testing for PE in patients presenting to the ED with syncope in our large, integrated health care system. MethodsWe performed a retrospective, longitudinal cohort study of patients who presented with syncope to EDs within a 21‐hospital integrated health care system from 2010 to 2015 to find the frequency and diagnostic yield of testing for PE in patients with syncope at index ED visit and within 180 days afterward. ResultsWe screened 2 749 371 ED encounters to find 32 440 (1.2%) with syncope. Median age was 52 (interquartile range, 31‐71), 57.5% were female, and 90% were Caucasian. PE was diagnosed on the index ED visit in 259 (0.8%; 95% confidence interval [CI], 0.7%‐0.9%) cases. Assessment for suspected PE with D‐dimer occurred in 5089 (15.7%) patients, and 2338 (7.2%) underwent computed tomography pulmonary angiography (CTPA). The yield of CTPA was 7.9%. PE was detected in 2.2% in whom a D‐dimer was performed. From index visit to 180 days, 467 (1.4%; 95% CI, 1.3%‐1.6%) patients were diagnosed with a PE, and 1051 (3.2%, 95% CI, 3.0%‐3.4%) patients died. ConclusionDiagnostic testing for PE is frequent in patients with syncope presenting to the EDs of a large, integrated health care system. The yield of diagnostic testing is low.

Test for respiratory and asthma control in preschool kids in the emergency department as a predictor of wheezing exacerbations.

The test for respiratory and asthma control in kids (TRACK score) is a standardized questionnaire tool validated to identify poor symptom control in children with stable preschool wheeze. This study determined if TRACK score measured within 5 days of an Emergency Department (ED) visit for acute wheezing predicts a subsequent wheezing exacerbation requiring an ED visit and/or treatment with systemic corticosteroids within 3 months. This was a single-center prospective cohort study of children aged 36 to 71 months who presented to the ED with an acute episode of wheezing and had TRACK score measured at a clinic visit within 5 days of the index ED encounter, focused on information about symptoms occurring before the onset of the current acute episode. The outcomes were the independent association of a repeat wheezing exacerbation with the overall TRACK score (primary) and with mutually uncorrelated TRACK items (secondary), adjusted for sex and atopy. We enrolled 102 children; median age 52.3 (44.1, 59.9) months, 59% males. Of these, 33 (32.4%) had further wheezing exacerbations. For each 10 unit decrease in TRACK, the odds of a future exacerbation was 1.38 (95% CI, 1.10-1.75); male sex demonstrated OR, 5.13 (1.84-14.33). A model that included TRACK items reflecting more than equal to 1 awakenings for wheezing in the past 4 weeks, receipt of more than equal to 2 courses of corticosteroids in the last year and male sex was predictive of wheezing exacerbations: OR, 6.43 (2.18-19.00). In preschoolers with acute wheezing episodes in the ED, we have identified the TRACK score components which, together with male sex, can be used to identify children at risk of future exacerbations requiring referral for specialized care. These results need to be confirmed and validated in other populations enrolled at multiple sites before they can be implemented in practice.

Further Utilization of Emergency Department and Inpatient Psychiatric Services Among Young Adults Admitted at the Emergency Department With Clinical Alcohol Intoxication.

To assess in a cohort of young adults admitted with alcohol intoxication (AI) to the Emergency Department (ED): how many patients are readmitted to the ED or to a Psychiatric Department (PD) inpatient unit; and which characteristics are associated with further ED and PD inpatient admissions. In 630 patients aged 18 to 30 years admitted for AI in 2006 to 2007 to the ED of a Swiss tertiary hospital, further ED and PD inpatient admissions through 2013 were assessed. Patient characteristics at the index (initial) ED visit were assessed using administrative and medical records. Proportion of subjects with at least 1 further ED admission, 1 further ED admission with AI, and any PD admission over the study period.Associations between patients' characteristics at index visit and readmissions were assessed using backward selection multivariate regression analyses. Mean age was 24, 66% were male, 60% had any ED/PD admissions during the study period, 17.9% a PD admission, and 13.8% were re-admitted to ED with AI. Disruptive behavior at the index visit was associated with further ED (odds ratio [OR] 1.69 [1.13; 2.54]) and PD admissions (OR 2.41 [1.44; 4.05]). Psychiatric diagnosis was associated with any further ED admission (OR 2.07 [1.41; 3.05]), with further ED admission with AI (OR 4.56 [2.36; 8.81]) and with PD admission (OR 3.92 [2.40; 6.41]). Female sex predicted any further ED admission (OR 1.65 [1.14; 2.39]). Young adults presenting with alcohol intoxication have high rates of subsequent inpatient emergency and psychiatric admissions. Being female, presenting with disruptive behavior, and having a psychiatric diagnosis at the ED visit were predictors of further admissions.

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study.

We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome. This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow-up and had institutional medical records reviewed in 3weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation. We enrolled 2,302 children (mean [±SD] age=9.0 [4.4]years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval=6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician's pretest probability of a fracture was≤20% versus>20% (adjusted odds ratio [aOR]=1.6), patient's pain score was≤2 versus>2 (aOR=1.6), and injury was located in a joint versus other location (aOR=1.7). Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.

Association of Suicide and Other Mortality With Emergency Department Presentation

Emergency departments (EDs) have the potential to play a pivotal role in suicide risk detection and prevention, yet little is known about the profile of risk of suicide after ED visits in the United States. To examine 1-year incidence of suicide and other mortality among ED patients who presented with nonfatal deliberate self-harm, suicidal ideation, or any other chief concern, and to examine sociodemographic and clinical factors associated with suicide mortality risk. This retrospective cohort study included statewide, all-payer, longitudinally linked ED patient records and mortality data from all California residents who presented to a California-licensed ED at least 1 time from January 1, 2009, to December 31, 2011, with deliberate self-harm, suicidal ideation but not self-harm, or neither (a 5% random sample). Age-, sex-, and race/ethnicity-adjusted standardized mortality ratios (SMRs) for suicide and other manners or causes of death were determined for each patient group using statewide mortality data. Data were analyzed from January 10 to July 18, 2019. Suicide and other manners or causes of death were ascertained using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Suicide rate and all mortality rates were measured per 100 000 person-years. Among 648 646 individuals (mean [SD] age, 43.8 [20.6] years; 350 687 [54.1%] women) who visited an ED in California from 2009 to 2011, the rates of suicide deaths per 100 000 person-years in the year after index ED presentation were 693.4 deaths among 83 507 individuals presenting with deliberate self-harm (SMR, 56.8; 95% CI, 52.1-61.4), 384.5 deaths among 67 379 individuals presenting with suicidal ideation but not self-harm (SMR, 31.4; 95% CI, 27.5-35.2), and 23.4 deaths among 497 760 reference patients (SMR, 1.9; 95% CI, 1.6-2.3). Compared with the demographically matched general population, the rates of nonsuicide external-cause mortality were also increased among patients with self-harm (SMR, 14.2; 95% CI, 12.9-15.5), patients with suicidal ideation (SMR, 11.8; 95% CI, 10.6-13.0), and reference patients (SMR, 2.2; 95% CI, 2.0-2.3). In all 3 groups, the rates of suicide mortality per 100 000 person-years were higher among men (deliberate self-harm: 1011.1 deaths; suicidal ideation: 539.8 deaths; reference: 36.6 deaths), people 65 years or older (deliberate self-harm: 1919.5 deaths; suicidal ideation: 691.2 deaths; reference: 28.6 deaths), and non-Hispanic white patients (deliberate self-harm: 914.1 deaths; suicidal ideation: 511.6 deaths; reference: 33.8 deaths) than among their respective referent groups. Other sociodemographic factors and clinical diagnoses were associated with striking differences in suicide rates, but these patterns were heterogeneous across patient groups. These findings suggest that ED patients with deliberate self-harm or suicidal ideation are associated with substantially increased risk of suicide and other mortality during the year after ED presentation. The process of planning for ED discharge may present opportunities to help ensure safe transitions to continuing outpatient mental health care and to consider broader risk for unintentional injury and other causes of premature mortality.

Impact of cardiology follow-up care on treatment and outcomes of patients with new atrial fibrillation discharged from the emergency department.

The first presentation of atrial fibrillation (AF) is often to an emergency department (ED). We evaluated the association of subsequent specialist care with morbidity and mortality. Retrospective cohort study of all adults in Alberta, Canada, with a new primary diagnosis of AF treated and released during an index ED visit between 2009 and 2015. Types of physician follow-up within 3 months of ED visit was analysed using Cox proportional hazards models with time-varying covariates. Outcomes were evaluated at 1 year. Of 7986 patients, 476 (6.0%) had no physician follow-up within 3 months, whereas 2730 (34.2%) attended a non-specialist only, 1277 (16.0%) an internal medicine specialist, and 3503 (43.9%) cardiology. An increasing gradient of cardiac investigations occurred across these groups. Cardiology compared with non-cardiologist care was associated with approximately two-fold greater electrophysiology interventions and revascularization, and increased use of beta-blockers (48.9% vs. 43.0%, P < 0.0001), statins (31.4% vs. 26.7%, P < 0.0001), and oral anticoagulation in patients with CHADS2 scores ≥1 (53.7% vs. 43.6%, P < 0.0001). In the subsequent year, cardiology care was associated with fewer deaths [adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.55-0.93], strokes (aHR 0.60, 95% CI 0.37-0.96), or major bleeds (aHR 0.69, 95% CI 0.53-0.89). No differences in the risk of hospitalization or ED visits were associated with cardiology care. Cardiology care after an ED visit for symptomatic new-onset AF is associated with better prognosis. The benefit may be mediated through more intensive investigation, identification, and treatment of cardiovascular risk factors and disease.

Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults.

Transitional care nurse (TCN) care has been associated with decreased hospitalizations for older adults in the emergency department (ED). The objective of this study was to evaluate the association between TCN care and readmission for geriatric patients who visit the ED within 30days of a prior hospital discharge. We studied a prospective cohort of ED patients aged 65 and older with an ED visit within 30days of inpatient discharge. Patients with an Emergency Severity Index of 1 or prior TCN contact were excluded. Entropy balancing and logistic regression were used to estimate the average incremental effect of the TCN intervention on risk of admission during the index ED visit and within 30days of prior discharge. Of 6,838 visits, 608 included TCN care. TCN patients had lower risk of readmission during the index ED visit at Mount Sinai Medical Center (MSMC), -10.1 percentage points (95% confidence interval [CI]= -18.5 to -2.7), and Northwestern Memorial Hospital (NMH), -17.3 percentage points (95% CI= -23.1 to -11.5), but not St. Joseph's Regional Medical Center (SJRMC), -2.5 percentage points (95% CI= -10.5 to 5.5). TCN patients had fewer readmissions within 30days of prior hospital discharge at NMH, -16.2 percentage points (95% CI= -22.0 to -10.3), but not at MSMC, -5.6 percentage points (95% CI= -13.1 to 1.8), or at SJRMC, 0.5 percentage points (95% CI= -7.2 to 8.2). Transitional care nurse care in the ED after a prior hospitalization was associated with decreased readmission of older adults during the index ED visit at two of three hospitals, with sustained reduction for the entire 30-day readmission window at one hospital. TCN interventions in the ED may decrease readmissions for geriatric patients in the ED; however, these results may be dependent on implementation of the program and availability of ED, hospital, and local resources for older adults.

Evaluating the Feasibility of an Emergency Department Physical Therapy Intervention for Acute Low Back Pain

Purpose: Integration of physical therapists into the emergency department (ED) setting is a relatively new practice in the United States. It is currently unknown whether patients are able to retain the skills and knowledge delivered during a brief ED physical therapy (PT) intervention, and whether patients participate in recommended home exercises or follow-up for a return visit. Methods: This is a prospective feasibility study of 30 ED patients with acute low back pain who were evaluated by an ED physical therapist, given individualized instruction in 3 prescribed home exercises, and discharged home with both printed and online instructions of the 3 prescribed exercises. Enrolled patients returned 1 week after their initial ED visit for an in-person demonstrated performance evaluation of the prescribed home exercises; patients also self-reported the frequency of home exercise performance in the week after ED discharge. Results: Thirty patients were enrolled, and 27 patients (90.0%) returned for the in-person evaluation at a median of 7.5 days. The most frequently prescribed exercises were prone positioning to press up on elbows (70.4% of participants), transverse abdominal contraction with posterior pelvic tilt (70.4%), and supine lower trunk rotation (44.4%). Twenty of 27 patients (74.0%) were able to successfully demonstrate performance of all 3 prescribed exercises. Participants reported performing any home exercise a median of 3 times (interquartile range 2-5) in the week following their index ED visit. Conclusions: A brief PT intervention delivered in the ED for acute low back pain is feasible with respect to patient follow-up, demonstrated performance of prescribed home exercises, and participation in home exercise therapy.

Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study.

Self-harm is increasing among adolescents, and because of changing behaviours, current data are needed on the consequences of self-harm. We sought to investigate the trends related to hospital presentation, readmission, patient outcome and medical costs in adolescents who presented with self-harm to the emergency department. We used administrative data on 403 805 adolescents aged 13-17 years presenting to Ontario emergency departments in 2011-2013. Adolescents with self-harm visits were 1:2 propensity matched to controls with visits without self-harm, using demographic, mental health and other clinical variables. Five years after the index presentation, hospital or emergency department admission rates for self-harm, overall mortality, suicides and conservative cost estimates were compared between the 2 groups. Of 5832 adolescents who visited Ontario emergency departments in 2011-2013 after self-harm (1.4% of visits), 5661 were matched to 10 731 adolescents who presented for reasons other than self-harm. Adolescents who presented with self-harm had a shorter time to a repeat emergency department or hospital admission for self-harm (hazard ratio [HR] 4.84, 95% confidence interval [CI] 4.44-5.27), more suicides (HR 7.96, 95% CI 4.00-15.86), and higher overall mortality (HR 3.23, 95% CI 2.12-4.93; p < 0.001). The positive predictive value of self-harm-related emergency department visits for suicide was 0.7%. Adolescents with self-harm visits had mean 5-year estimates of health care costs of $30 388 compared with $19 055 for controls (p < 0.001). Adolescents with emergency department visits for self-harm have higher rates of mortality, suicide and recurrent self-harm, as well as higher health care costs, than matched controls. Development of algorithms and interventions that can identify and help adolescents at highest risk of recurrent self-harm is warranted.

Predicting Emergency Department "Bouncebacks": A Retrospective Cohort Analysis.

IntroductionThe short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored.MethodsThis was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 – June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit.ResultsAmong 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 – 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 – 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 – 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 – 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 – 1.528; Medicare OR 1.601; 95% CI, 1.583 – 1.620).ConclusionPrevious ED use – even a single previous visit – was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.

128 In-Hospital Outcomes After Emergency Department Revisit in Taiwan: A Nationwide Analysis

Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies focusing on in-hospital outcomes following ED revisits have begun to challenge this notion. To our knowledge, there have been no studies that utilize nationwide data to address this issue. We aimed to examine in-hospital clinical outcomes and resource use among patients who are hospitalized following a return visit to the ED using a national database. This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2011 to 2013 were randomly selected and their hospitalizations were included. The in-hospital outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay and cost) were analyzed comparing patients who were hospitalized after a return visit to the ED within 3 days vs. patients who were hospitalized during the index ED visit. Multivariable regression models were used to adjust for differences in patient mix. There were 5,575,044 index ED visits during the 3-year study period. Of them, 1,075,892 (19%) were admitted to the hospital following the index ED visit. Among the 4,499,152 patients who were discharged during the index ED visit, 319,772 had a return visit to the ED within 3 days. Of them, 79,999 (25%) were admitted to the hospital. The in-hospital mortality rates were similar between the two groups (3% in the revisit-admission group vs 3% in the direct-admission group, p=0.79). Compared with the direct-admission group, the revisit-admission group had a lower ICU admission rate (2.5% vs. 3.0%, p<0.001), a shorter mean length of stay (8.4 vs. 8.6 days, p<0.001) and lower mean costs (40,954 vs. 48,146 TWD, p<0.001). After adjusting for age, sex, and 29 comorbidities, the patterns of outcome differences persisted, with similar inpatient mortality between the two groups and slightly better outcomes and lower resource use in the revisit-admission group. Patients who were hospitalized after a return visit to the ED within 3 days did not experience worse outcomes or consume more resources than those who were directly admitted during the index ED visit. Our findings suggest that ED revisit is multifactorial and does not necessarily relate to emergency care quality.

1 Risk of Emergency Department Revisit or Hospitalization in Older Adults Discharged With Potentially Inappropriate Medications: A Retrospective Cohort Study

Vulnerable elderly patients are prone to multiple co-morbidities that warrant the need for several long-term prescriptions or “polypharmacy.” Polypharmacy strongly correlates with higher risk of prescribing potentially inappropriate medications (PIMs). In 1991 Mark H. Beers, a geriatrician, led the first published consensus on guidelines for PIMs commonly prescribed nationwide (Beers criteria). Geriatric emergency physicians’ question if Beers criteria are equally as effective in an emergency department (ED) setting where prescriptions are intended for short term use only. In other words, do short-term PIMs pose the same risks of ED returns and hospitalization as PIMs prescribed for 3 months or longer? To determine whether PIMs prescribed to older adults discharged from the ED increases the risk of subsequent ED revisits or hospital admissions within 3 and 30 days from ED discharge. A retrospective cohort observational study of adults 65 years and older discharged with prescription(s) from the Mount Sinai Hospital ED in New York City, January 2012 to November 2015. Hospital electronic medical records were identified for unique subjects prescribed PIMs at ED discharge versus those prescribed non PIMs from 2012 to 2015. PIMs are defined following the 2015 Beers criteria. For ED returns to hospitals other than Mount Sinai, patient records were linked up to their Medicare claims 30 days following their index visit. Primary outcomes were frequency and incident rates of ED revisits and hospitalization within 3 and 30 days (D) post index ED discharge. Secondary outcomes were rates and reasons of hospital admissions over 3 and 30 days in both groups. Descriptive and bivariate analysis, including Chi-square test, are currently underway. A total of 31,521 unique patients made a total of 71,484 ED visits during the study period. Mean age was 76.1 years (8.52 SD), 57.44% were female. Of these, 7,659(20.45%) were discharged from the ED with a medication prescription: 1,567 (20.46%) were considered PIM prescriptions (vs. 79.54% were non-PIMs). There were 39,962 return visits to Mount Sinai Hospital (MSH), 55.9%. 112 patients died during the study period. Though extensively reported in geriatric care literature, studies on PIM prescriptions that focus on the short term yet urgent ED setting are rare. This study addresses a hotly debated topic in geriatric emergency practice today.