Index Emergency Department Visit Research Articles

Post–COVID-19 Condition in Children 6 and 12 Months After Infection

There is a need to understand the long-term outcomes among children infected with SARS-CoV-2. To quantify the prevalence of post-COVID-19 condition (PCC) among children tested for SARS-CoV-2 infection in pediatric emergency departments (EDs). Multicenter, prospective cohort study at 14 Canadian tertiary pediatric EDs that are members of the Pediatric Emergency Research Canada network with 90-day, 6-month, and 12-month follow-up. Participants were children younger than 18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. Data were analyzed from May to November 2023. The presence of SARS-CoV-2 infection at or within 14 days of the index ED visit. Presence of symptoms and QoL reductions that meet the PCC definition. This includes any symptom with onset within 3 months of infection that is ongoing at the time of follow-up and affects everyday functioning. The outcome was quantified at 6 and 12 months following the index ED visit. Among the 5147 children at 6 months (1152 with SARS-CoV-2 positive tests and 3995 with negative tests) and 5563 children at 12 months (1192 with SARS-CoV-2 positive tests and 4371 with negative tests) who had sufficient data regarding the primary outcome to enable PCC classification, the median (IQR) age was 2.0 (0.9-5.0) years, and 2956 of 5563 (53.1%) were male. At 6-month follow-up, symptoms and QoL changes consistent with the PCC definition were present in 6 of 1152 children with positive SARS-CoV-2 tests (0.52%) and 4 of 3995 children with negative SARS-CoV-2 tests (0.10%; absolute risk difference, 0.42%; 95% CI, 0.02% to 0.94%). The PCC definition was met at 12 months by 8 of 1192 children with positive SARS-CoV-2 tests (0.67%) and 7 of 4371 children with negative SARS-CoV-2 tests (0.16%; absolute risk difference, 0.51%; 95% CI, 0.06 to 1.08%). At 12 months, the median (IQR) PedsQL Generic Core Scale scores were 98.4 (90.0-100) among children with positive SARS-CoV-2 tests and 98.8 (91.7-100) among children with negative SARS-CoV-2 tests (difference, -0.3; 95% CI, -1.5 to 0.8; P = .56). Among the 8 children with SARS-CoV-2 positive tests and PCC at 12-month follow-up, children reported respiratory (7 of 8 patients [88%]), systemic (3 of 8 patients [38%]), and neurologic (1 of 8 patients [13%]) symptoms. In this cohort study of children tested for SARS-CoV-2 infection in Canadian pediatric EDs, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed PCC, and overall QoL did not differ from children with negative SARS-CoV-2 tests.

Association between Acute Pain Scores in Children with Sickle Cell Disease and Emergency Department Disposition and Return Visit Rates

Introduction Reducing pain through prompt administration of pain medication in the emergency department (ED) is a primary driver of national guidelines for sickle cell disease (SCD), yet there are few data on how pain scores and changes in pain scores are associated with both the disposition at the initial visit and the likelihood of a return visit. In this study, we analyzed acute pain scores from ED visits for children with uncomplicated SCD pain crisis to determine the relationships between pain scores and disposition (admission or discharge) or occurrence of a return ED visit. Objectives For children with uncomplicated SCD pain crises, we aimed to determine (1) the association between initial pain score, last pain score, change in pain scores and the disposition of index ED visits, and (2) the association between these pain score values, number of parenteral opioid doses in the ED, whether an opioid prescription was provided at discharge, and an ED return visit within 14 days. Methods This is a multicenter retrospective cohort study of acute pain scores of ED visits by children for uncomplicated SCD pain crises. It was conducted using electronic health care data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry across 7 sites (Lurie Children's, Children's Hospital of Philadelphia, Cincinnati Children's Hospital, Children's National Medical Center, Children's Colorado, Children's Wisconsin, and Nationwide Children's). Index ED visits were defined as uncomplicated pain crises with no preceding ED visits within 14 days between 01/2017 - 11/2021. We collected the following ED pain scores: initial, last, and change in scores (initial minus last) as measured by a numeric rating scale (0-10). For analyses related to disposition, we modeled the relationship between the three pain scores and hospital disposition adjusting for age, sex and uncomplicated pain crisis visit admission rate. For analyses related to return visits, we utilized the same predictor variables and added both the number of parenteral opioid doses administered in the ED and whether or not a prescription for an opioid was given at discharge. For all analyses, adjustment for site was made using generalized estimating equations with an exchangeable correlation structure to account for clustering within site. Modified Poisson regression was used to identify associations. SAS software version 9.4 was used for all statistical analyses. Results A total of 4,985 index visits for uncomplicated SCD pain crisis were included; 52% resulted in hospitalization. Overall, 39% of the children were <12 years old, 54% were female, and 96% were Black. Eligible index ED visits per site varied from 157 to 1855. The overall ED median (IQR) initial pain score was 8.0 (6.0-10).The median last pain score was 5.0 (2.0-8.0); median change in ED pain score was 2.0 (0.0-5.0). In univariate analyses, higher initial and last pain scores and a smaller change in pain scores were all associated with higher hospitalization rates. Adjusted rate ratios (95% CI) from multivariable models showed last pain score was the best predictor of admission 1.16 (1.12, 1.19), with change in pain score no longer significant 0.98 (0.96, 1.00). Examining percent of children hospitalized by last pain score shows over 80% of children with a last pain score of 7 or higher were hospitalized, compared to less than 40% if 4 or lower (Figure 1). 29% of the 2,377 visits that were originally discharged to home had a return visit within 14 days. None of the included pain scores from the initial visit (initial, last, or change) were associated with having a return visit within 14 days. However, both an increased number of ED opioid doses and failure to receive a prescription for an opioid at discharge were associated with increased return visits. Figure 2 shows the ED opioid doses and prescription for opioid combination and their respective return visit rates, with a high of 36% for ≥ 3 doses of ED opioid doses and no prescription and a low of 22% if 1 opioid given and a prescription at discharge. Conclusions: We found that for a child with SCD presenting to the ED with an uncomplicated pain crisis, the last ED pain score was a better predictor of hospitalization than initial or change in pain score. None of those pain scores predicted a return visit after discharge; however, fewer opioid doses in the ED and receipt of an opioid prescription at discharge were associated with fewer return visits.

2843. Risk Factors for Unplanned Healthcare Encounters in Patients Discharged from the Emergency Department with Extended-spectrum β-lactamase Urinary Tract Infections

Abstract Background The management of extended spectrum β-lactamase (ESBL) urinary tract infections (UTIs) in the emergency department (ED) has not been well documented in literature. The purpose of this study was to describe treatment and outcomes of patients with ESBL UTIs in the ED, which can inform best practices for antimicrobial stewardship. Methods This IRB approved, retrospective cohort analysis included patients who were discharged from the ED with an ESBL UTI between January 2020 and November 2022. The primary outcome of interest was any unplanned healthcare encounter related to the UTI within 30 days of the index ED visit, which included phone/virtual visits, clinic visits, ED visits, and hospitalizations. Patients ≥18 years of age treated for symptomatic UTI with a monomicrobial urine culture were included, while those with altered mental status, history of renal transplant, abnormal urinary tract, or were on active antibiotic therapy prior to the ED visit were excluded. Patient characteristics, initial and definitive antibiotic therapy, culture results including pathogen and susceptibilities were described. Logistic regression analysis was used to identify any exposures that were independently associated with unplanned healthcare encounters related to the UTI. Results 162 patients were included; 103 (64%) had an unplanned healthcare encounter. Patient characteristics are depicted in Table 1. Complicated lower UTI was most frequent occuring in 71 patients (44%). Susceptibility data revealed that nitrofurantoin was effective in 121 (75%) patients, aminoglycosides in 117 (72%) patients, TMP/SMX in 66 (41%) patients, and quinolones in 62 (38%) patients. 76 (74%) patients with unplanned encounters received an inactive empiric prescription: β-lactams being prescribed to 52 (51%) patients with cephalexin used for 49/52 (94%). Of the 81 patients with lower UTI, 20 (25%) initially received a prescription for nitrofurantoin. Factors associated with an unplanned healthcare encounter are described in Table 2.Table 2.Factors Associated with Unplanned Healthcare Encounters. Abbreviations: Un-Adj OR = unadjusted odds ratio; Adj OD = adjusted odds ratio Conclusion Patients discharged from the ED with an ESBL UTI were at higher risk for unplanned healthcare encounters if they had CKD or were initially prescribed an oral β-lactam. Prescribing first line therapy with nitrofurantoin for lower UTI is a potential area for improvement. Disclosures Michael Veve, PharmD, MPH, National Institutes of Health: Grant/Research Support|Paratek Pharmaceuticals: Grant/Research Support

Abstract 16662: Factors Associated With Repeated Emergency Department Visits Among Symptomatic Patients With Heart Failure

Heart failure (HF) is a prevalent cause of emergency department (ED) visits among adults. However, there is limited understanding of the characteristics of patients with HF who frequently utilize the ED for symptom management. Aim: To describe factors associated with ED revisits among symptomatic patients with chronic HF. Methods: We identified 1,472,083 adults (age ≥ 18 years) with HF who had no history of left ventricular assist device or heart transplantation between January 2010 and March 2020 from the TriNetX Research Network, which included 47 US healthcare organizations. In this retrospective observational study, 24,070 patients presenting with dyspnea and receiving intravenous (IV) Furosemide at the ED were followed up for 1 year from the index ED visit. ED revisits related to the treatment of dyspnea with IV diuretics were tracked. Factors associated with these ED revisits were identified using multivariate Cox regression analysis. Results: A total of 3,574 ED revisits were observed from 2,559 patients (10.6% of the sample, mean age 63 years, 51% men, 39% White, 62% Non-Hispanic). The ED revisit rates were 52, 96, 125, and 148 visits per 1,000 persons within 1, 3, 6, and 12 months, respectively. The median time to the first ED revisit for symptom management with IV diuretics was 65 days (range 2-364 days). In the Cox model, younger patients (< 65 years) had a higher risk of ED revisits compared to older patients (HR 1.65, 95% CI 1.50-1.82, p<0.001). Men had a higher risk of ED revisits compared to women (HR 1.12, 95% CI 1.02-1.23, p=0.02). Black patients had a higher risk of ED revisits compared to other races (HR 1.36, 95% CI 1.20-1.53, p<0.001). Patients with HFrEF (e.g., ICD-10 I50.2) had a higher risk of ED revisits compared to those with congestive HF (e.g., ICD-10 I50 without HF type information) (HR 1.25, 95% CI 1.12-1.40, p < 0.001). Patients diagnosed with HF more than 1 year prior to the index ED visit had a higher risk of ED revisits compared to those diagnosed within 1 year (HR 1.31, 95% CI 1.19-1.44, p < 0.001). Conclusions: Younger age, male gender, Black race, HFrEF classification, and longer duration of HF were associated with ED revisits among symptomatic adults with HF. To reduce repeated ED visits, targeted interventions for high-risk patients are essential.

Risk factors for recurrent emergency care utilization for flares in inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) need frequent emergency care due to flares of their disease. However, understanding which patients are most vulnerable to repeat emergency care due to recurrent flares of their disease remains poor. This was a retrospective cohort study of Kaiser Permanente Northern California health plan members aged ≥18 years between 2009 and 2018. Our primary outcome was occurrence of repeat emergency department (ED) visits with a primary diagnosis code of IBD in the 6 months following their index ED visit. Baseline characteristics and clinical service use patterns were extracted. We used multivariable negative binomial regression analysis to measure the incident risk of a recurrent ED visit within 6 months. We found 2111 patients who met eligibility criteria, of whom 56.7% were female and 39.7% were non-White. During the 6-month observation period, 19.3% (n = 408) returned to the ED for a second IBD flare. In adjusted analyses, we found older age (incident risk ratio [IRR] 0.44, 95% confidence interval [CI] 0.31-0.62 for age 60+ compared to 18-30), higher neighborhood household income (IRR 0.80, 95% CI 0.65-0.98 for income ≥$85,000), and diagnosis of alcohol use disorder were associated with a lower risk of repeat ED utilization (IRR 0.62, 95% CI 0.41-0.93), while presence of mood disorder (IRR 1.26, 95% CI 1.03-1.58), history of opiate prescription (IRR 1.38, 95% CI 1.10-1.73), and corticosteroid prescription (IRR 1.57, 95% CI 1.27-1.95) were associated with increased risk of repeat ED utilization. Prompt outpatient follow-up was not associated with a lower odds of recurrent ED utilization (IRR 0.93, 95% CI 0.75-1.15). Our study identified multiple patient characteristics associated with higher recurrent short-term use of the ED for IBD care. Although we did not find prompt outpatient follow-up after initial ED visit to be protective, targeted interventions directed at high-risk individuals based on mood disorders, opiate use, or steroid use may help to optimize care and health care utilization.

Outcomes of Emergency Department Patients With Opioid Use Disorder Utilizing a Virtual Addiction Bridge Clinic: A Case Series.

Within the last decade, there has been a dramatic increase in the rate of emergency department (ED) visits and death from opioid overdose. Those who present to the ED are at high risk for subsequent morbidity and mortality. Despite effective treatment, many patients do not get rapidly connected to outpatient care. The aim of this investigation was to describe outpatient treatment engagement after ED discharge among patients with opioid use disorder (OUD) enrolled in a virtual Addiction Bridge Clinic (ABC). This was a retrospective case series describing an ED-initiated referral for rapid telehealth follow-up among patients with OUD. The primary outcome was addiction treatment engagement among those who completed the initial virtual ABC visit (engaged in ABC) vs. those who did not complete an ABC visit (Not engaged in ABC) at 1 week, 1 month, and 3 and 6 months timepoint intervals after the initial ED presentation. Of the N = 201 patients referred to the ABC between March and December 2021, a majority were Black (71%) and male (77%). Of the 201 referrals, 85 (42%) completed an initial ABC telehealth visit. Subsequent treatment engagement was 26% at 1 week, 26% at 1 month, 22% at 3 months, and 18% at 6 months after the index ED visit. A telehealth-enabled virtual addiction bridge clinic is one potential approach to reduce barriers to rapid treatment access. Strategies are needed to improve subsequent addiction treatment engagement after a virtual addiction bridge clinic visit.

Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study

BackgroundThe objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. MethodsWe conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. ResultsA total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). ConclusionsThe implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.

Myocardial Infarction Within 30 Days of Discharge From an Emergency Department: A Descriptive Study of Albertan Women

BackgroundCardiovascular diseases (CVDs) are the leading cause of premature death for Canadian women, which may be due partly to a lack of awareness of the presentation of acute coronary events in emergency departments (EDs). To address an identified gap in women’s cardiovascular care, we sought to describe the clinical and comorbid factors of women who, following discharge from an ED, suffered a myocardial infarction (MI). MethodsDescriptive analyses were completed on a cohort of women who presented to an ED in Alberta, Canada, between January 1, 2010 and December 31, 2020, were discharged, and within 30 days of their index ED visit, were admitted to the hospital with an MI. The cohort was explored for clinical and comorbid data, ED visits pre-MI, type of MI, and presenting complaint/ primary diagnosis for the index ED visit. Results1380 women were included in this analysis with a mean age of 67 (standard deviation ±13) years. The frequencies of hypertension, diabetes, and dyslipidemia among the youngest women, aged 18-45 years, were 47.5%, 31.3%, and 48.8%, respectively. Women across all ages demonstrated a high prevalence of traditional CVD risk factors, and 22% of women presented to an ED 2 or more times within the 30 days pre-MI. ConclusionsRegardless of their age, the women in this cohort had notable CVD risk factors. Future research is required to better understand the phenomenon of women presenting multiple times to an ED pre-MI. Research is needed on life-stage–specific factors of women presenting to EDs pre-MI, to help reduce MI incidence.

Emergency Department Bridge Model and Health Services Use Among Patients With Opioid Use Disorder

Little is known about the effectiveness of bridge clinics as transitional care programs for people with opioid use disorder in emergency departments (EDs). We assessed the effect of bridge clinic referral on health services use among patients with opioid use disorder identified in the ED. We used data for individuals aged 18 years and over with active opioid use disorder and no history of medication for opioid use disorder who were administered medication for opioid use disorder while in the ED between January 2013 and August 2022. Bridge clinic referrals started in January 2021. Eligible patients after this date comprised the intervention group. The usual care group included eligible patients before bridge clinic implementation, who were a 1:1 propensity score matched to intervention patients. We estimated risk differences and 95% confidence limits for linkage to long-term care, ED use, and inpatient admission within 120 days of the index ED visit. Our study population comprised 928 observations after matching. Patients referred to the bridge clinic had a higher risk of linkage to long-term care (risk differences=25%; 95% confidence limits: 20%, 30%), higher risk of ED use (risk differences=7.5%, 95% confidence limits: 1.6%, 13%), and lower risk of inpatient admission (risk differences= -1.9%, 95% confidence limits: -5.9%, 2.1%). Inpatient admission increased among patients with serious mental illness but decreased among patients without serious mental illness. Our overall results suggest that bridge clinic referral increases linkage to long-term care. Nevertheless, qualitatively different effects on inpatient admission between patients with and without serious mental illness warrant consideration of unmet needs among patients with serious mental illness.

Critical Revisits Among Children After Emergency Department Discharge

Identifying higher risk groups could reveal ways to prevent critical emergency department (ED) revisits. The study objectives were to determine the rate of critical ED revisits among children discharged from the ED and to identify factors associated with critical revisits. We performed a retrospective study using the Healthcare Cost and Utilization Project State ED Databases (SEDD) and the State Inpatient Databases (SID). We included data from 6 states from 2014 through 2017. Critical ED revisit was defined as either ICU admission or death within 3 days of the initial ED discharge. We included all patients younger than 21 years. The main outcome was the rate of critical ED revisit. We also determined the relative risk (RR) of a critical ED revisit for the most common index ED visit diagnoses. We used negative binomial regression to calculate incidence rate ratios (IRR) of a critical ED visit by pediatric volume and complex chronic conditions. A total of 16.3 million children were discharged from an ED over the 4-year study period. There were 18,704 (0.1%) critical ED revisits, 180 (0.00001%) of whom died. Asthma (RR 2.24, 95% confidence interval [CI] [2.11 to 2.38) had the highest relative risk of a critical revisit among all ED diagnoses. Adjusting for hospital volume and patient age, patients with complex chronic conditions were also more likely to have a critical ED revisit (IRR 11.03, 95% CI, 7.76 to 15.67). Critical revisits after ED discharge were uncommon among children in our study sample, with revisits resulting in patient death within 3 days of an ED discharge being rare. Given the short time interval between ED discharges, however, future research should focus on understanding higher risk patients among those with asthma and a history of complex chronic conditions.

Accuracy of Self-Reported COVID-19 Vaccination Status Compared With a Public Health Vaccination Registry in Québec: Observational Diagnostic Study.

The accuracy of self-reported vaccination status is important to guide real-world vaccine effectiveness studies and policy making in jurisdictions where access to electronic vaccine registries is restricted. This study aimed to determine the accuracy of self-reported vaccination status and reliability of the self-reported number of doses, brand, and time of vaccine administration. This diagnostic accuracy study was completed by the Canadian COVID-19 Emergency Department Rapid Response Network. We enrolled consecutive patients presenting to 4 emergency departments (EDs) in Québec between March 24, 2020, and December 25, 2021. We included adult patients who were able to consent, could speak English or French, and had a proven COVID-19 infection. We compared the self-reported vaccination status of the patients with their vaccination status in the electronic Québec Vaccination Registry. Our primary outcome was the accuracy of the self-reported vaccination status (index test) ascertained during telephone follow-up compared with the Québec Vaccination Registry (reference standard). The accuracy was calculated by dividing all correctly self-reported vaccinated and unvaccinated participants by the sum of all correctly and incorrectly self-reported vaccinated and unvaccinated participants. We also reported interrater agreement with the reference standard as measured by unweighted Cohen κ for self-reported vaccination status at telephone follow-up and at the time of their index ED visit, number of vaccine doses, and brand. During the study period, we included 1361 participants. At the time of the follow-up interview, 932 participants reported at least 1 dose of a COVID-19 vaccine. The accuracy of the self-reported vaccination status was 96% (95% CI 95%-97%). Cohen κ for self-reported vaccination status at phone follow-up was 0.91 (95% CI 0.89-0.93) and 0.85 (95% CI 0.77-0.92) at the time of their index ED visit. Cohen κ was 0.89 (95% CI 0.87-0.91) for the number of doses, 0.80 (95% CI 0.75-0.84) for the brand of the first dose, 0.76 (95% CI 0.70-0.83) for the brand of the second dose, and 0.59 (95% CI 0.34-0.83) for the brand of the third dose. We reported a high accuracy of self-reported vaccination status for adult patients without cognitive disorders who can express themselves in English or French. Researchers can use self-reported COVID-19 vaccination data on the number of doses received, vaccine brand name, and timing of vaccination to guide future research with patients who are capable of self-reporting their vaccination data. However, access to official electronic vaccine registries is still needed to determine the vaccination status in certain susceptible populations where self-reported vaccination data remain missing or impossible to obtain. Clinicaltrials.gov NCT04702945; https://clinicaltrials.gov/ct2/show/NCT04702945.

Frequencies and reasons for unplanned emergency department return visits by older adults: a cohort study

BackgroundAs unplanned Emergency Department (ED) return visits (URVs) are associated with adverse health outcomes in older adults, many EDs have initiated post-discharge interventions to reduce URVs. Unfortunately, most interventions fail to reduce URVs, including telephone follow-up after ED discharge, investigated in a recent trial. To understand why these interventions were not effective, we analyzed patient and ED visit characteristics and reasons for URVs within 30 days for patients aged ≥ 70 years.MethodsData was used from a randomized controlled trial, investigating whether telephone follow-up after ED discharge reduced URVs compared to a satisfaction survey call. Only observational data from control group patients were used. Patient and index ED visit characteristics were compared between patients with and without URVs. Two independent researchers determined the reasons for URVs and categorized them into: patient-related, illness-related, new complaints and other reasons. Associations were examined between the number of URVs per patient and the categories of reasons for URVs.ResultsOf the 1659 patients, 222 (13.4%) had at least one URV within 30 days. Male sex, ED visit in the 30 days before the index ED visit, triage category “urgent”, longer length of ED stay, urinary tract problems, and dyspnea were associated with URVs. Of the 222 patients with an URV, 31 (14%) returned for patient-related reasons, 95 (43%) for illness-related reasons, 76 (34%) for a new complaint and 20 (9%) for other reasons. URVs of patients who returned ≥ 3 times were mostly illness-related (72%).ConclusionAs the majority of patients had an URV for illness-related reasons or new complaints, these data fuel the discussion as to whether URVs can or should be prevented.Trial registrationFor this cohort study, we used data from a randomized controlled trial (RCT). This trial was pre-registered in the Netherlands Trial Register with number NTR6815 on the 7th of November 2017.

Factors associated with mild bronchiolitis in young infants.

Bronchiolitis within the first 3 months of life is a risk factor for more severe illness. We aimed to identify characteristics associated with mild bronchiolitis in infants ≤90 days old presenting to the emergency department (ED). We conducted a secondary analysis of infants ≤90 days old with clinically diagnosed bronchiolitis using data from the 25th Multicenter Airway Research Collaboration prospective cohort study. We excluded infants with direct intensive care unit admissions. Mild bronchiolitis was defined as (1) sent home after the index ED visit and did not have a return ED visit or had a return ED visit without hospitalization, or (2) were hospitalized from the index ED visit to the inpatient floor for<24hours. Multivariable logistic regression, adjusting for potential clustering by hospital site, was used to identify factors associated with mild bronchiolitis. Of 373 infants aged ≤90 days, 333 were eligible for analysis. Of these, 155 (47%) infants had mild bronchiolitis, and none required mechanical ventilation. Adjusting for infant characteristics, clinical factors associated with mild bronchiolitis included older age (61-90 days vs 0-60 days) (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.52-4.87), adequate oral intake (OR 4.48, 95% CI 2.08-9.66), and lowest ED oxygen saturation ≥94% (OR 3.12, 95% CI 1.55-6.30). Among infants aged ≤90 days presenting to the ED with bronchiolitis, about half had mild bronchiolitis. Mild illness was associated with older age (61-90 days), adequate oral intake, and oxygen saturation ≥94%. These predictors may help in the development of strategies to limit unnecessary hospitalization in young infants with bronchiolitis.

Emergency department use by patients who received chimeric antigen receptor T cell infusion therapy.

Chimeric antigen receptor T cell infusion (CAR T) therapy has revolutionized the treatment of hematologic malignancies, but treatment-related toxicities are of concern. Understanding the timing and reasons for which patients present to the emergency department (ED) after CAR T therapy can assist with the early recognition and management of toxicities. A retrospective observational cohort study was conducted for patients who had undergone CAR T therapy in the past 6 months and visited the ED of The University of Texas MD Anderson Cancer Center between 04/01/2018 and 08/01/2022. The timing of presentation after CAR T product infusion, patient characteristics, and outcomes of the ED visit were examined. Survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. During the period studied, there were 276 ED visits by 168 unique patients. Most patients had diffuse large B-cell lymphoma (103/168; 61.3%), multiple myeloma (21/168; 12.5%), or mantle cell lymphoma (16/168; 9.5%). Almost all 276 visits required urgent (60.5%) or emergent (37.7%) care, and 73.5% of visits led to admission to the hospital or observation unit. Fever was the most frequent presenting complaint, reported in 19.6% of the visits. The 30-day and 90-day mortality rates after the index ED visits were 17.0% and 32.2%, respectively. Patients who had their first ED visit >14 days after CAR T product infusion had significantly worse overall survival (multivariable hazard ratio 3.27; 95% confidence interval 1.29-8.27; P=0.012) than patients who first visited the ED within 14 days of CAR T product infusion. Cancer patients who receive CAR T therapy commonly visit the ED, and most are admitted and/or require urgent or emergent care. During early ED visits patients mainly present with constitutional symptoms such as fever and fatigue, and these early visits are associated with better overall survival.

Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals.

Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage. We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit. Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics. A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p< 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit. Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit. This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.

Biliary colic in the emergency department: A state-wide analysis of one-year costs and clinical outcomes

ImportanceApproximately 335,000 cases of biliary colic present to US emergency departments (EDs) annually, and most patients without complications are discharged from the ED. It is unknown what are the subsequent surgery rates, subsequent complications of biliary disease, ED revisits, repeat hospitalizations and cost; and, how does the ED disposition decision (admission versus discharge) affect long-term outcomes. ObjectiveTo determine whether there is a difference in one-year surgery rates, complications of biliary disease, ED revisits, repeat hospitalizations, and cost in ED patients with uncomplicated biliary colic who are admitted to the hospital versus those that are discharged from the ED. Design, setting, and participantsA retrospective observational study was conducted using records collected from the Maryland Healthcare Cost and Utilization Project (HCUP) in the Ambulatory Surgery, the Inpatient, and the ED setting between 2016 and 2018. After applying inclusion criteria, 7036 ED patients with uncomplicated biliary colic were followed for one year after their index ED visit for repeat healthcare utilization across multiple settings. A multivariable logistic regression study was performed to asses for risk factors for surgery allocation and hospital admission. Medicare Relative Value Units (RVUs) and HCUP Cost-Charge Ratio files were used to estimate direct costs. ExposuresEpisodes of biliary colic were ascertained using ICD-10 codes at the index ED visit. Main outcomes and measuresThe primary outcome was the one-year surgery rate, defined as a cholecystectomy. Secondary outcomes included the rate of new acute cholecystitis or other related complications, ED revisits, hospital admission and costs. Associations with hospital admission and surgeries were measured using adjusted odds ratios (ORs) with 95 % CIs. ResultsOf the 7036 patients analyzed, 793 (11.3 %) were admitted and 6243 (88.7 %) were discharged on their initial ED visit. When comparing the groups who were initially admitted versus discharged, we observed similar one-year cholecystectomy rates (42 % versus 43 %, mean difference 0.5 %, 95 % CI −3.1 %–4.2 %; P < 0.001), lower rates of new cholecystitis occurrences (18 % versus 41 %, mean difference 23 %, 95 % CI, 20 %–26 %; P < 0.001), lower rates of ED revisits (96 vs 198 per 1000 patients, mean difference 102, 95 % CI, 74–130; P < 0.001) and higher costs ($9880 versus $1832, mean difference 8048, 95 % CI, 7478–8618; P < 0.001). Initial ED hospital admission was associated with increased age (adjusted odds ratio [aOR], 1.44; 95 % CI, 1.35–1.53; P < 0.001), obesity (aOR, 1.38; 95 % CI, 1.32–1.44; P < 0.001), ischemic heart disease (aOR, 1.39; 95 % CI, 1.30–1.48; P < 0.001), mood disorders (aOR, 1.18; 95 % CI, 1.13–1.24; P < 0.001), alcohol-related disorders (aOR, 1.20; 95 % CI, 1.12–1.27; P < 0.001), hyperlipidemia (aOR, 1.16; 95 % CI, 1.09–1.23; P < 0.001), hypertension (aOR, 1.15; 95 % CI, 1.08–1.21; P < 0.001), and nicotine dependence (aOR, 1.09; 95 % CI, 1.03–1.15; P = 0.003) but not associated with race (P > 0.9), ethnicity (P > 0.9), or income-stratified zip code (aOR, 1.04; 95 % CI, 0.98–1.09; P = 0.17). Conclusions and relevanceIn our analysis of ED patients with uncomplicated biliary colic from a single state, the majority of patients do not receive a cholecystectomy within one year and hospital admission at the initial visit was not associated with an overall change in rates of cholecystectomy but was associated with increased costs. These findings inform our understanding of the long-term outcomes and are important considerations when communicating care options with ED patients with biliary colic.

Prognostic association between d-dimer thresholds and 30-day pulmonary embolism diagnosis among emergency department patients with suspected SARS-CoV-2 infection: a Canadian COVID-19 Emergency Department Rapid Response Network study.

The primary objective was to quantify the prognostic association between various D-dimer thresholds and 30-day PE diagnosis among emergency department (ED) patients with suspected SARS-CoV-2 infection. This was a retrospective study of patients enrolled in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) registry from March 1, 2020 to July 2, 2021. We included consecutive adults (≥ 18years) presenting to 49 EDs with chest pain, shortness of breath, hypoxia, syncope, presyncope, or hemoptysis who were tested for both SARS-CoV-2 and D-dimer at index ED visit. The primary outcome measure was the sensitivity, specificity, and negative predictive value of D-dimer test thresholds for the outcome of 30-day PE diagnosis. Among 10,837 patients included in our study, 404 (3.7%) were diagnosed with PE at 30-days. A standard D-Dimer threshold of 500ng/mL had a sensitivity of 97.8% (95% confidence interval [CI] 95.8-99.0%), specificity of 40.9% (95% CI 39.9-41.8%), and negative predictive value of 99.8% (95% CI 99.6-99.9%). An age-adjusted D-dimer threshold had a sensitivity of 96.0% (95% CI 93.6-97.7%), specificity of 48.5% (95% CI 47.5-49.4%), and negative predictive value of 99.7% (95% CI 99.5-99.8%). D-dimer testing had slightly lower prognostic performance among SARS-CoV-2 positive compared to SARS-CoV-2 negative patients in predicting 30-day PE diagnosis. Among ED patients with suspected SARS-CoV-2, the standard 500ng/mL and age-adjusted D-dimer thresholds were comparable for the prediction of PE at 30-days. The prognostic performance of D-dimer was lower among SARS-CoV-2 positive patients. Clinicaltrials.gov, NCT04702945.

Characterization of potentially avoidable neurological emergency department visits at a large urban public hospital

This study characterized potentially avoidable neurological emergency department (ED) visits at a large urban public hospital. This was a retrospective review of Parkland Health (Dallas, TX) data from May 15, 2021, to July 15, 2021. The study population included encounters discharged home from the ED with any of the following: a primary neurological ED diagnosis, a neurological consultation in the ED, or a neurology clinic referral placed during the ED encounter. Neurovascular, strokelike, acute trauma, and nonneurological cases were excluded. The primary outcome was the number of ED visits by diagnosis category. A total of 965 ED discharge encounters met study criteria as potentially avoidable neurological ED visits, far higher than total neurology-related admissions over the same 2-month period. Headache (66%) and seizure/epilepsy (18%) syndromes were the most common. Thirty-five percent of all cases had neurology involvement in either the ED or the outpatient setting. This was lowest for headache (19%). The revisit rate within 3 months of the index ED visit was 29%, and it was highest for seizures/epilepsy (48%). Potentially avoidable nonvascular neurological ED visits occur frequently, especially for headache and seizure disorders. This study highlights the need for quality improvement and delivery innovation initiatives to optimize the site of care for patients with chronic neurological conditions.

Abstract 13239: Variation in Cost by HEART Score in Patients With Suspected Acute Coronary Syndrome

Introduction: The variation in medical cost by risk stratification using history, electrocardiogram, age, risk factors and troponin (HEART), after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS), is not well understood. Hypothesis: We hypothesized that annual total all cause cost will increase significantly with increasing HEART score and the primary driver of the total cost will be cardiovascular disease (CVD) related care. Methods: This was a retrospective cohort study of adults (age ≥18) with chest pain and complete data for HEART score, presenting at EDs within the Kaiser Permanente Southern California health system from 1/2016-12/2018. We analyzed direct medical cost associated with medical office visits, hospital facility and ED visits, pharmacy utilization, hospice stays, skilled nursing stays, home health, dialysis, laboratory, and radiology utilization during the 1-year following the index ED visit. Stratified by HEART score categories, we used one part and two part generalized linear models (log link &amp; gamma family distribution) adjusted for socio-demographics, cardiovascular disease (CVD) history and treatment and non-CVD comorbidities, to estimate average adjusted total all cause expenditure as well as subgroups of utilization. Results: The cohort included 33,990 patients (60% Low risk; 37% intermediate risk and 3% high risk). The adjusted annual total cost varied from $6,544 (95% CI $6,228 to $6,860) in the low risk to $21,210 ($19,458 to $22,962) in the high-risk group (Table 1). In each group, the primary driver of total cost was CVD related care accounting for 41% to 46% of total cost. CVD care provided in a hospital setting accounted for 44%-76% of CVD total cost. Conclusions: Increased follow-up medical office visits, improved medications and lifestyle management may reduce the near exponential increase in cost driven by catastrophic hospital utilization, in higher HEART risk stratified patients.

Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged From the Emergency Department With Supplemental Oxygen

To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.