Initial Emergency Department Visit Research Articles

Return to the Emergency Department Within 3 Months Following Pediatric Acute Concussion.

To determine the proportion of concussed children returning to the emergency department (ED) for a concussion-related reason within 3 months of initial presentation and to determine which clinical composite score (5P or Post-Concussion Symptom Inventory) best predicts a return visit. We combined a secondary analysis of data from the prospectively collected 5P study with a retrospective medical record review of children aged 5 to 18 years who returned to the Children's Hospital of Eastern Ontario (CHEO) ED for a concussion-related reason within 3 months of an acutely diagnosed concussion. Among 770 eligible participants, 632 children (median age: 11.8 [interquartile range (IQR), 9.0-14.5] years; 58.9% male) were included in the study. The primary outcome was the number of patients who returned to CHEO ED for a concussion-related reason within 3 months of an acute concussion diagnosed at CHEO ED. The secondary outcome was number of patients who returned within 14 days. Forty-seven children (7.4%; 95% confidence interval [CI]: 5.6-9.7) had a concussion-related return to the ED within 3 months, the majority of which occurred in the first 14 days (29/47; 61.7%; 95% CI: 47.4-74.2). History of migraines (21.3% vs 9.7%; P = .03) were more common in those with a return visit. Headache was the most frequently reported symptom (87.2%) on revisit. Females aged 13 to 18 years had the highest return rate (survival rate: 85.8% [95% CI: 79.8-92.3]) compared with males and younger age groups. In multivariable Cox hazards regression modeling, inclusion of risk scores improved prognostication (pseudo R2 = 8%). The difference in pseudo R2 between 5P and Post-Concussion Symptom Inventory is small. Most children and adolescents do not return to the ED following an acute concussion. Female youth with medium to high 5P scores at the index concussion visit may benefit from early referral to interdisciplinary specialty concussion care to guide treatment in anticipation of prolonged symptoms. By identifying these risk factors at the initial ED visit, healthcare and patient burden may be reduced.

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.

Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis

BackgroundAdvanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians’ burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD).ObjectivesTo compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs.MethodsThis trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time.DiscussionMSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD.Trial registrationClinicalTrials.govNCT05545917. Registered on September 19, 2022

The Association of Antimicrobial Prophylaxis With Return Visits After Dog Bites in Children.

Dog bites occur frequently in the United States, yet there are no clear guidelines for prescribing antibiotic prophylaxis in healthy children after a dog bite. The aim of our study was to assess antibiotic prophylaxis and subsequent rates of infection after dog bites in children. We hypothesized a negative association between prophylactic prescription of any antimicrobial and return visit within 14 days for infection. In this retrospective cohort study, we assessed the frequency of antibiotic prophylaxis prescribed after dog bite injuries in patients 0 to 18 years old and subsequent return visits for infection using 2016 to 2017 medical and pharmacy claims derived from the IBM MarketScan Research Databases. We used the International Classification of Diseases-10 code W54 for dog bites then used keyword searches to find diagnoses (including infection), wound descriptions, and medications. Over the 2-year period, 22,911 patients were seen for dog bites that were not coded as infected. The majority, 13,043 (56.9%), were prescribed an antibiotic at the initial visit and 9868 (43.1%) were not. Of those prescribed antibiotics, 98 (0.75%; 95% confidence interval [CI], 0.60-0.90) returned with an infection, compared with 59 (0.60%; 95% CI, 0.44-0.75) of those not prescribed antibiotics. Receiving an antibiotic prescription at the initial visit was associated with a reduced rate of return for wound infection only among children whose wounds were repaired or closed. Children not receiving a prescription whose wounds were repaired were more than twice as likely to return with an infection in the subsequent 14 days as children whose wounds were not repaired (odds ratio, 2.2; 95% CI, 1.2-4.0). Most children are prescribed antibiotics at an initial emergency department visit after a dog bite. However, very few return for infection independent of antimicrobial prophylaxis, which suggests antibiotics are overprescribed in this setting.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated. To assess the interventions and patient factors associated with ED return following an initial ED visit for HS. This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022. Factors analyzed included those associated with the ED visit and patient characteristics. Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit. This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days). This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Physician Practice Style and Healthcare Costs: Evidence from Emergency Departments

We study healthcare operations of emergency departments (EDs) by examining the practice styles and skills of ED physicians. Our data include all residents of Montreal, Canada, with an initial ED visit in Montreal during a nine-month period. For each visit, our data record the initial treating hospital, ED physician, ED billed expenditures, and all interactions with the health system within the subsequent 90 days. Physicians in Montreal rotate across shifts between simple and difficult cases, implying a quasi-random assignment of patients to physicians within an ED. We consider three medical conditions that present frequently in the ED and for which mistreatment may have dramatic consequences—angina, appendicitis, and transient ischemic attacks—jointly examining diagnostic and disposition skills. To control for variation in diagnosis, our sample for each condition consists of patients with a broader set of symptoms and signs potentially indicative of the condition. Separately by condition, we regress healthcare usage and cost measures on indicators for physicians to estimate the skill and practice style of each physician. We then evaluate the variation across physicians in their practice style and skills and the correlations between different measures of skill and practice style. We find significant variation across physicians in their practice styles and skills. We also find that physicians with costly practice styles often have worse outcomes in terms of more ED revisits and more hospitalizations. Finally, the practice styles and skills of physicians correlate positively across the three conditions that we consider. This paper was accepted by Jayashankar Swaminathan, operations management. Funding: Gowrisankaran acknowledges funding from the Center for Management Innovations in Healthcare at the University of Arizona. Supplemental Material: The online appendix and data are available at https://doi.org/10.1287/mnsc.2022.4544 .

Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department.

Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated. Cohort study using administrative data from Ontario of patients ≥ 65years presenting to theED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90days of the initial ED visit for a head injurywhere no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status. 69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1). There was an increased odds of delayed intracranial hemorrhage within 90days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.

Patients with complicated gallstone disease in the emergency department: clinical impact and cost-effectiveness of emergency department disposition decision.

ObjectiveThe objective of this study was to assess the 1‐year outcomes of emergency department (ED) patients with complicated gallstone disease, including surgery rates, initial admission rates, ED revisits, repeat hospitalizations, and cost.MethodsUsing 3 linked statewide databases from the Maryland Healthcare Cost and Utilization Project, we identified patients with a primary diagnosis of complicated gallstone disease treated in an ED between 2016 and 2018. We measured the healthcare use and direct costs in the ambulatory surgery, inpatient, and ED settings for 1 year after the initial ED visit. Finally, we performed a multivariate logistic regression analysis comparing initially admitted versus discharged patients.ResultsOf the 8751 patients analyzed, 86.8% were admitted to the hospital and 13.2% were discharged on their initial ED visit. Of the admitted patients, 78.7% received a cholecystectomy during the initial hospitalization plus 6.1% at a later date; of the discharged patients, 41.5% received a cholecystectomy. Admitted patients demonstrated lower recurrent gallbladder complications compared with those discharged (7.5% vs 44.5%), fewer ED revisits (4% vs 20.3%), and fewer repeat hospitalizations (4.5% vs 16.7%). Despite this, the 1‐year cost in the admitted patients was higher ($9448 vs $2933). Obesity, age, and mood disorders but not race, ethnicity, or zip code were associated with admission at initial ED visit.ConclusionsIn our single‐state analysis of ED patients with complications of gallstone disease, most patients are admitted on the initial visit and receive a cholecystectomy during that hospitalization. The discharged group had higher rates of 1‐year complications, ED revisits, and repeat hospitalizations but lower cost.

Effect of a Peer-Led Behavioral Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose

Fatal and nonfatal opioid overdoses are at record levels, and emergency department (ED) visits may be an opportune time to intervene. Peer-led models of care are increasingly common; however, little is known about their effectiveness. To evaluate the effect of a peer-led behavioral intervention compared with the standard behavioral intervention delivered in the ED on engagement in substance use disorder (SUD) treatment within 30 days after the ED encounter. This randomized clinical trial recruited 648 patients from 2 EDs from November 15, 2018, to May 31, 2021. Patients were eligible to participate if they were in the ED for an opioid overdose, receiving treatment related to an opioid use disorder, or identified as having had a recent opioid overdose. Participants were randomly assigned to receive a behavioral intervention from a certified peer recovery specialist (n = 323) or a standard intervention delivered by a hospital-employed licensed clinical social worker (n = 325). A certified peer recovery specialist was someone with at least 2 years of recovery who completed a 45-hour training program and had 500 hours of supervised work experience. After the ED intervention, the certified peer recovery specialists offered continued contact with participants for up to 90 days. The primary outcome was receipt of SUD treatment within 30 days of enrollment, assessed with deterministic linkage of statewide administrative databases. Treatment engagement was defined as admission to a formal, publicly licensed SUD treatment program or receipt of office-based medication for opioid use disorder within 30 days of the initial ED visit. Among the 648 participants, the mean (SD) age was 36.9 (10.8) years, and most were male (442 [68.2%]) and White (444 [68.5%]). Receipt of SUD treatment occurred for 103 of 323 participants (32%) in the intervention group vs 98 of 325 participants (30%) in the usual care group within 30 days of the ED visit. Among all participants, the most accessed treatments were outpatient medication for opioid use disorder (buprenorphine, 119 [18.4%]; methadone, 44 [6.8%]) and residential treatment (44 [6.8%]). Overall, this study found that a substantial proportion of participants in both groups engaged in SUD treatment within 30 days of the ED visit. An ED-based behavioral intervention is likely effective in promoting treatment engagement, but who delivers the intervention may be less influential on short-term outcomes. Further study is required to determine the effects on longer-term engagement in SUD care and other health outcomes (eg, recurrent overdose). ClinicalTrials.gov Identifier: NCT03684681.

Syncope and the Risk of Subsequent Motor Vehicle Crash

Medical driving restrictions are burdensome, yet syncope recurrence while driving can cause a motor vehicle crash (MVC). Few empirical data inform current driving restrictions after syncope. To examine MVC risk among patients visiting the emergency department (ED) after first-episode syncope. A population-based, retrospective observational cohort study of MVC risk after first-episode syncope was performed in British Columbia, Canada. Patients visiting any of 6 urban EDs for syncope and collapse were age- and sex-matched to 4 control patients visiting the same ED in the same month for a condition other than syncope. Patients' ED medical records were linked to administrative health records, driving history, and detailed crash reports. Crash-free survival among individuals with syncope was then compared with that among matched control patients. Data analyses were performed from May 2020 to March 2022. Initial ED visit for syncope. Involvement as a driver in an MVC in the year following the index ED visit. Crashes were identified using insurance claim data and police crash reports. The study cohort included 43 589 patients (9223 patients with syncope and 34 366 controls; median [IQR] age, 54 [35-72] years; 22 360 [51.3%] women; 5033 [11.5%] rural residents). At baseline, crude MVC incidence rates among both the syncope and control groups were higher than among the general population (12.2, 13.2, and 8.2 crashes per 100 driver-years, respectively). In the year following index ED visit, 846 first crashes occurred in the syncope group and 3457 first crashes occurred in the control group, indicating no significant difference in subsequent MVC risk (9.2% vs 10.1%; adjusted hazard ratio [aHR], 0.93; 95% CI, 0.87-1.01; P = .07). Subsequent crash risk among patients with syncope was not significantly increased in the first 30 days after index ED visit (aHR, 1.07; 95% CI, 0.84-1.36; P = .56) or among subgroups at higher risk of adverse events after syncope (eg, age >65 years; cardiogenic syncope; Canadian Syncope Risk Score ≥1). The findings of this population-based retrospective cohort study suggest that patients visiting the ED with first-episode syncope exhibit a subsequent crash risk no different than the average ED patient. More stringent driving restrictions after syncope may not be warranted.

Treatment of Acute Bronchitis and its Impact on Return Emergency Department Visits

BackgroundAntibiotics are not recommended in healthy, uncomplicated adults for the treatment of acute bronchitis, yet are still often prescribed. No randomized studies have examined whether prescribing antibiotics in the emergency department (ED) impacts hospital return rates. ObjectiveOur aim was to compare hospital return rates between those who were prescribed an antibiotic vs. those who were not prescribed an antibiotic for the treatment of acute bronchitis. MethodsA retrospective cohort study was completed evaluating patients aged 18–64 years who presented to a community teaching hospital ED with acute bronchitis between January 2017 and December 2019. The primary outcomes were 30-day ED return and hospital admissions from initial ED visit. The rates of ED return or readmitted were compared for patients prescribed an antibiotic for treatment of acute bronchitis vs. those patients who were not prescribed an antibiotic. ResultsOf the 752 patients included, 311 (41%) were prescribed antibiotics. Baseline demographics were similar between both groups. Of those prescribed an antibiotic, 26 of 311 (8.4%) returned to the hospital within 30 days compared with 33 of 441 patients (7.5%) who were not prescribed an antibiotic (odds ratio 1.13; 95% confidence interval 0.66–1.92). ConclusionsThere was no association found between antibiotic therapy for treatment of acute bronchitis and return to the hospital.

The impact of learner involvement in emergency department patient assessments on short-term return visits requiring hospital admission: a cross-sectional study.

Learners, either medical students or residents, often perform the initial assessment of patients visiting the emergency department (ED). It is unclear, however, if learners affect the rate of short-term unscheduled return visits. The objective of this study was to determine if the involvement of learners in ED visits increases the rate of return visits. This was a retrospective cross-sectional analysis of ED visit data at a single tertiary care centre over a 1-year period. Return visits were defined as those presenting within 72h of discharge from an initial non-admit ED visit and resulting in an admission on the second visit. A generalized linear mixed model was used to determine the odds ratios of return visits, adjusting for prespecified co-variates, with and without learners involved during the initial visit. Secondary analyses assessed for associations between learner level of training, program of study and return visits. Return visits occurred after 658 (1.3%) of 51,149 encounters involving learners and 701 (0.8%) of 83,310 encounters with no learner involvement. Involvement of learners in ED initial visits was not associated with increased odds of return visits (adjusted OR 1.13 [95% CI 0.71-1.81]), although the point estimates were heterogeneous over learner level of training, with clerkship students (medical student years 3 and 4) and senior residents (post-graduate years 4 and 5) trending towards reduced odds of a return visit. Resident program of study did not independently predict return visits. This study demonstrated that the involvement of learners in ED patient assessments is not associated with increased odds of short-term unscheduled return visits.

Antibiotic use and impact on illness course in children with influenza-like-illness in the emergency department

Background: Child absenteeism from childcare or school leads to economic loss from parental work absenteeism, overutilization of acute-care resources, and excess medicalization of children with minor illnesses. We sought to determine the difference in days missed from childcare or school and days of illness for children with influenza-like illness (ILI) in the emergency department (ED) who are or are not prescribed an antibiotic. Methods: We conducted a secondary data analysis of a prospective randomized control trial evaluating the impact of rapid molecular testing on provider decision making. The study included children aged 2 months–12 years attending childcare or school seen in the ED from December 2018 through December 2019 with ILI (CDC definition) with parental survey completion 10 days after their ED visit. The primary exposure was receipt of antibiotics over the course of illness, which was assessed by chart review and parent survey. The primary outcome was number of days missed from class. The secondary outcome was number of days of illness after initial ED visit. Wilcoxon tests were used to compare missed class days or illness days by antibiotic receipt. Multivariable negative binomial regression was used to analyze outcomes, controlling for clinically important patient characteristics. Results: Of 251 children included in this study, the median age was 4.2 years (IQR, 1.6–7.0); 52% were male, 40% were White, 54% were Hispanic, and 75% had government insurance. Antibiotics were prescribed in 26% of ILI encounters. There was no statistically significant association between antibiotic receipt and number missed class days (2.0 days [IQR, 1.0–4.0] vs 3.0 days [IQR, 1.0–5.0]; P = .08) or illness days (4.0 days [IQR, 3.0–7.0] vs 5.0 days [IQR, 3.0–7.0]; P = .13) after the initial ED visit. After adjusting for covariates, there was no significant difference in missed class days or illness days for patients prescribed antibiotics in relation to days sick before ED visit. The rates of missed class days and illness days were 87% and 30% greater, respectively, in patients with additional medical visits during the course of illness. Conclusions: Days sick prior to ED presentation and receipt of an antibiotic for ILI had no influence on child absenteeism or illness duration. However, children missed more class and received more antibiotics if they had multiple medical visits during an illness. Further study is needed on sociobehavioral factors leading to medicalization of children with minor illnesses and its impact on the unnecessary use of antibiotics.Funding: NoneDisclosures: None

Follow-Up After Asthma Emergency Department Visits and Its Relationship With Subsequent Asthma-Related Utilization.

To assess the association between follow-up after an asthma-related emergency department (ED) visit and the likelihood of subsequent asthma-related ED utilization. Using data from California Medicaid (2014-2016), and Vermont (2014-2016) and Massachusetts (2013-2015) all-payer claims databases, we identified asthma-related ED visits for patients ages 3 to 21. Follow-up was defined as a visit within 14 days with a primary care provider or an asthma specialist. asthma-related ED revisit after the initial ED visit. Models included logistic regression to assess the relationship between 14-day follow-up and the outcome at 60 and 365 days, and mixed-effects negative binomial regression to assess the relationship between 14-day follow-up and repeated outcome events (# ED revisits/100 child-years). All models accounted for zip-code level clustering. There were 90,267 ED visits, of which 22.6% had 14-day follow-up. Patients with follow-up were younger and more likely to have commercial insurance, complex chronic conditions, and evidence of prior asthma. 14-day follow-up was associated with decreased subsequent asthma-related ED revisits at 60 days (5.7% versus 6.4%, P < .001) and at 365 days (25.0% versus 28.3%, P < 0.001). Similarly, 14-day follow-up was associated with a decrease in the rate of repeated subsequent ED revisits (66.7 versus 77.3 revisits/100 child-years; P < 0.001). We found a protective association between outpatient 14-day follow-up and asthma-related ED revisits. This may reflect improved asthma control as providers follow the NHLBI guideline stepwise approach. Our findings highlight an opportunity for improvement, with only 22.6% of those with asthma-related ED visits having 14-day follow-up.

Triage Travel Screening in the Pediatric ED: A Cross-Sectional Analysis to Evaluate Current Use and Effectiveness in Identifying Travel Related Illness

ObjectivesIn 2014 the Center for Disease Control and Prevention recommended emergency departments (EDs) implement triage travel screening to identify persons at risk for Ebola Virus Disease (EVD). EVD remains rare in the United States, and in practice the triage travel screen serves as a de facto screen for all travel-related illnesses. This study seeks to determine the current use and effectiveness of the triage travel screen to detect travel-related illness in the pediatric ED. MethodsThis was a retrospective, cross-sectional study of visits across three pediatrics EDs in 2019 in Atlanta, GA. Prevalences of travel-related illnesses were compared between patients with positive and negative travel screens. Patient charts with diagnoses of travel-related illness were then reviewed. ResultsOut of 244,841 patient encounters during the study period, 13 patients with travel-related illness were identified. 5/13 cases of travel-related illness were not diagnosed at the initial ED visit. Of these 5 cases, 2 had correctly negative travel screens (as travel was not within the specified timeframe) and 3 had correctly positive travel screens, but none had a clinician-documented travel history in the ED clinical notes. Of the 8/13 cases that were diagnosed at the initial ED visit, 7/8 had a clinician-documented travel history in the ED note. ConclusionsThis study highlights the limitations of the current pediatric ED triage travel screen to detect travel-related illness and reinforces the importance of a provider-taken travel history. Strategies to increase provider-administered travel history documentation and revisions to increase triage travel-screen efficacy should be considered.

Multisystem inflammatory syndrome in adults: a\xa0case report\xa0and review of the literature

BackgroundThe current coronavirus disease pandemic has brought recognition of multisystem inflammatory syndrome in adults as a de novo entity, temporally associated with severe acute respiratory syndrome coronavirus 2 viral infection in adults. Hypothesis about its true pathophysiology remains controversial.Case reportThe patient was a 22-year-old African American female presenting to the emergency department with fever, sore throat, and neck swelling for the past 3 days. During her initial emergency department visit, her blood pressure was stable at 110/57 mmHg, temperature of 39.4 °C, and heart rate of 150 beats per minute. While in the emergency department, she received broad-spectrum antibiotics (vancomycin and ceftriaxone) and 30 cc/kg bolus of normal saline. Originally, she was admitted to a telemetry floor. The following night, a rapid response code was called due to hypotension. At that time, her blood pressure was 80/57 mmHg. She appeared comfortable without signs of respiratory distress. She received intravenous fluids and vasopressors, and was transferred to the intensive care unit. The patient had reported a previous coronavirus disease infection a few weeks prior. She was diagnosed and treated for multisystem inflammatory syndrome in adults. Intravenous immunoglobulin infusion was initiated and completed on hospital day 5. She was weaned off vasopressors by day 6, and discharged home on day 11.ConclusionOur case report is an example of the presentation, diagnosis, and management of multisystem inflammatory syndrome. Our research into previous case reports illustrates the wide range of presentations, degree of end organ damage, and treatment modalities. This diagnosis needs to be considered in the presence of recent coronavirus disease infection with new-onset end organ failure, as prompt diagnosis and treatment is crucial for better outcomes.

Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers

There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown. To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers. In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021. ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. Time to death within 365 days. Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses. Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.

Predicting mid-term survival of patients during emergency department triage for resuscitation decision

In patients with non-small cell lung cancer (NSCLC) visiting the emergency department (ED), clinical decisions must be made based on their disease prognosis. This study aims to predict the disease outcome of patients visiting the ED for the first time after NSCLC diagnosis. This study included patients who visited the ED in 2016–2020 after being diagnosed with NSCLC in study site or within 30 days before the first outpatient clinic visit after diagnosis. Primary outcome of prediction model was 3-month mortality from the initial ED visit. We analyzed the association between outcome and each variable as a risk factor and built a prediction model using these variables. Both oncologic factors and ED-associated factors were associated with the 3-month mortality of NSCLC from the first ED visit. We also visualized the treatment trace as a sequence and utilized it in prediction model building. The areas under the receiver operating curve (AUROCs) of the prediction model of 3-month mortality from the first ED visit ranged from 0.677 (95% Confidence Interval (CI), 0.640–0.708) to 0.729 (95% CI, 0.697–0.761). This study provides the prediction model about 3-month survival in first ED visit point and identified patient and disease-related factors to predict the prognosis of patients.

294. Surveillance for Potential Post-Acute COVID-19 Syndrome Medical Complications in the Emergency Department (ED) – A Retrospective Longitudinal Study of ED Patients Who Had Evidence of SARS-CoV-2 Infection Versus Those Who Did Not

BackgroundAs the COVID-19 pandemic continues, growing attention has been placed on whether patients previously infected with SARS-CoV-2 have an increased risk of developing and/or exacerbating medical complications. Our study aimed to determine whether individuals with previous evidence of SARS-CoV-2 infection prior to their current emergency department (ED) visit were more likely to present with specific clinical sign/symptoms, laboratory markers, and/or clinical complications. MethodsA COVID-19 seroprevalence study was conducted at Johns Hopkins Hospital ED (JHH ED) from March 16 to May 31, 2020. Evidence of ever having SARS-CoV-2 infection (PCR positive or IgG Ab positive) was found in 268 ED patients at this time (i.e. infected and/or previously infected). These patients were matched 1:2 to controls, by date, to other patients who attended the JHHED. Clinical signs/symptoms, laboratory markers, and/or clinical complications associated with ED visits and/or hospitalizations at JHH within 6 months after their initial ED visit was abstracted through chart review for these 804 patients. Cox proportional hazards regression analyses were performed.ResultsAmong 804 ED patients analyzed, 50% were female, 56% Black race, and 15% Hispanic with a mean age of 47 years. 323 (40%) patients had at least 1 subsequent ED visit and additional 70 (9%) had been admitted to JHH. After controlling for race and ethnicity, patients with evidence of current or prior COVID-19 infection were more likely to require supplemental oxygen [hazards ratio (HR) =2.53; p=0.005] and have a cardiovascular complication [HR =2.13; p=0.008] during the subsequent ED visit than the non-infected patients. ConclusionOur findings demonstrate that those previously infected with SARS-CoV-2 have an increased frequency of cardiovascular complications and need for supplemental oxygen in ED visits in the months after their initial SARS-CoV-2 infection was detected. EDs could serve as a critical surveillance site for monitoring post-acute COVID-19 syndrome complications. Disclosures Richard E. Rothman, PhD, MD, Chem bio (Grant/Research Support)

Tips to Prevent Delayed Diagnosis of Pediatric Appendicitis

Research Article| December 01 2021 Tips to Prevent Delayed Diagnosis of Pediatric Appendicitis AAP Grand Rounds (2021) 46 (6): 64. https://doi.org/10.1542/gr.46-6-64 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Tips to Prevent Delayed Diagnosis of Pediatric Appendicitis. AAP Grand Rounds December 2021; 46 (6): 64. https://doi.org/10.1542/gr.46-6-64 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: appendicitis, delayed diagnosis Source: Michelson KA, Reeves SD, Grubenhoff JA, et al. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. JAMA Netw Open. 2021;4(8):e2122248. doi: https://doi.org/10.1001/jamanetworkopen.2021.22248Google Scholar Investigators from multiple institutions conducted a case control study to evaluate clinical features associated with a delayed diagnosis of appendicitis in children and to assess how frequently the delay in diagnosis might have been preventable. Study participants were patients <21 years old diagnosed with appendicitis at 1 of 5 pediatric emergency departments (EDs) in the US between 2010 and 2019. Cases were children with 2 ED visits within 7 days leading to a diagnosis of appendicitis and were identified by reviewing diagnostic codes available in the Pediatric Health Information System (PHIS). Controls were patients with a diagnosis of appendicitis made at the time of their initial ED visit who had been previously enrolled in a prospective study at 1 of the participating EDs between 2010 and 2013. Demographic and symptom information were collected systematically on control patients at the time of their ED visit. The medical records of cases were reviewed and demographic and clinical data from the 2 ED visits abstracted. Using a validated scoring system, the Modified Safer DX checklist, the record from the initial ED visit in cases was systematically reviewed and the preventability of the missed diagnosis classified as “likely,” “possibly,” or “unlikely” preventable. Logistic regression was used to compare the presence of specific clinical features of appendicitis observed during the initial ED visit for cases compared to ED visit in controls. In a second model, “care features” such as use of specific medications or imaging were included. Length of stay (LOS) and rates of perforation in cases and controls also were compared. Data were analyzed on 748 children with a mean age of 10.2 ±4.3 years, including 471 cases and 277 controls. Overall, 109 (23.1%) of delayed diagnoses of appendicitis in cases were judged to be unlikely preventable, 247 (52.4%) possibly, and 115 (24.4%) likely. Compared to clinical features in controls, at their initial ED visit case patients were significantly more likely to have abdominal pain present for 48-96 hours (vs <24 hours; odds ratio [OR], 2.84; 95% confidence interval [CI], 1.16, 4.97) and less likely to have pain with walking (OR, 0.16; 95% CI, 0.10, 0.25), maximal pain in right lower quadrant (OR, 0.12; 95% CI, 0.07, 0.19), or abdominal guarding (OR, 0.33; 95% CI, 0.21, 0.51). In the model including care features, cases were more likely to have received non-steroidal anti-inflammatory drugs (OR, 3.78; 95% CI, 2.10, 6.80) and ondansetron (OR, 1.99; 95% CI, 1.10, 3.61), less likely to have received opioids (OR, 0.26; 95% CI, 0.14, 0.49), and less likely to have an ultrasound examination (OR, 0.13; 95% CI, 0.08, 0.24). LOS was longer in cases than controls (mean difference, 2.8 days; 95% CI 2.3, 3.4), and risk of perforation was higher in cases (OR, 7.8; 95% CI, 5.5, 11.3). The authors... You do not currently have access to this content.