Inner-city Emergency Department Research Articles

Analyzing pain patterns in the emergency department: Leveraging clinical text deep learning models for real-world insights

ObjectiveTo determine the incidence of patients presenting in pain to a large Australian inner-city emergency department (ED) using a clinical text deep learning algorithm. Materials and methodsA fine-tuned, domain-specific, transformer-based clinical text deep learning model was used to interpret free-text nursing assessments in the electronic medical records of 235,789 adult presentations to the ED over a three-year period. The model classified presentations according to whether the patient had pain on arrival at the ED. Interrupted time series analysis was used to determine the incidence of pain in patients on arrival over time. We described the changes in the population characteristics and incidence of patients with pain on arrival occurring with the start of the Covid-19 pandemic. Results55.16% (95%CI 54.95%–55.36%) of all patients presenting to this ED had pain on arrival. There were differences in demographics and arrival and departure patterns between patients with and without pain. The Covid-19 pandemic initially precipitated a decrease followed by a sharp, sustained rise in pain on arrival, with concurrent changes to the population arriving in pain and their treatment. DiscussionApplying a clinical text deep learning model has successfully identified the incidence of pain on arrival. It represents an automated, reproducible mechanism to identify pain from routinely collected medical records. The description of this population and their treatment forms the basis of intervention to improve care for patients with pain. The combination of the clinical text deep learning models and interrupted time series analysis has reported on the effects of the Covid-19 pandemic on pain care in the ED, outlining a methodology to assess the impact of significant events or interventions on pain care in the ED. ConclusionApplying a novel deep learning approach to identifying pain guides methodological approaches to evaluating pain care interventions in the ED, giving previously unavailable population-level insights.

Enhancing pain care with the American Pain Society Patient Outcome Questionnaire for use in the emergency department (APS-POQ-RED): validating a patient-reported outcome measure

BackgroundIn general, the quality of pain care in emergency departments (ED) is poor, despite up to 80% of all ED patients presenting with pain. This may be due to the...

Utilization of the Disaster Medical Assistance Team (DMAT) in an Inner-City Emergency Department During the COVID-19 Pandemic.

To evaluate the effect of the Disaster Medical Assistance Team (DMAT) in an inner-city emergency department during the coronavirus disease (COVID-19) pandemic. Data were abstracted from individual emergency department encounters over 6 weeks. The study compared left without being seen (LWBS) percentage, door-to-provider, and door-to-disposition times for 2 weeks before, during, and after the DMAT. The LWBS percentages for the 2 weeks before and after the DMAT were 16.2% and 11.6%, respectively. The LWBS percentage during the DMAT was 8.1%. Door-to-disposition times for the 2 weeks before and after the DMAT were 7.36 hours and 8.53 hours, respectively. The door-to-disposition during the DMAT was 7.33 hours. Door-to-disposition was statistically significant during the 2 weeks of the DMAT compared to the 2 weeks after the DMAT (7.33 vs 8.53, P < 0.05) but not statistically significant when compared to the period before the DMAT (7.36 vs 7.33, P = 1.00). Door-to-provider time was the longest during the DMAT (122.5 minutes [2.04 hours]) when compared to the time frame before the DMAT (114.54 minutes [1.91 hours]) and after the DMAT (102.84 minutes [1.71 hours]). The DMAT had the most positive impact on LWBS percentages. The DMAT showed no improvement in door-to-provider times in the study and only in door-to-disposition times when comparing the time the DMAT was present to after the DMAT departed.

Predictors of severe and recurrent adult anaphylaxis, and gaps in the cascade of care: a retrospective, single-centre study 2009-2018.

Anaphylaxis is a severe, potentially fatal, systemic allergic reaction. Understanding predictors of recurrent and severe anaphylaxis in adults, and identifying gaps in ongoing anaphylaxis care, is needed to minimise its impact. To evaluate the risk factors in adults with severe and recurrent anaphylaxis presentations and to evaluate the management of patients in regard to the recommended cascade of care. We completed a retrospective audit of adults with confirmed anaphylaxis who presented to an inner-city emergency department from 1 January 2009 through 31 December 2018. Data recorded included demographics, background history, medication use, severity, co-factors, triggers, management, discharge disposition and referral for follow-up. Data were managed in REDCap and analysed using Stata. Associations were assessed through odds ratios (ORs) and t tests. Six hundred sixteen individuals had 689 episodes of anaphylaxis over the audit period. Age over 65 (OR: 5.4 (95% confidence interval, CI: 2.3-13.2), P < 0.0001) and history of asthma (OR: 1.6 (95% CI: 1.03-2.5), P = 0.03) were independent risk factors for severe anaphylaxis. History of food allergy (P < 0.001) and food as the trigger were associated with recurrent presentations (OR: 2.1, 95% CI: 1.1-3.9, P = 0.01). Only 19% of patients met the recommended cascade of care, with post-adrenaline monitoring and recommending follow-up with an allergy specialist demonstrating the largest gaps. There were increased presentations with time but no difference in triggers or severity. Increased age and asthma were identified as risk factors for severe presentations. History of food allergy was a risk factor for recurrent presentations. Further research is needed on the gaps in care for adults with anaphylaxis to identify the reasons why, so we can better care for these patients.

Characteristics of First Nations patients who take their own leave from an inner-city emergency department, 2016-2020.

Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave. Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed. A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P=0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P=0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001). A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.

Emergency Clinicians interpretation and application of Anti-D guidelines

Objective: The objective of this study was to audit the use of anti-D immunoglobulin (anti-D) against the current Australian guidelines in one large inner-city referral hospital over three years and critique the practice identified. Background: Pregnant patients who have a D-negative (RhD negative) blood type are at risk of D alloimmunisation if a potentially sensitising event occurs during pregnancy or birth. The administration of anti-D Ig can prevent complications related to alloimmunisation. Potentially sensitising events commonly present to the emergency department requiring the administration of anti-D Ig in line with current guidelines. Study Design and Methods: This is a retrospective cohort study of all patients who received anti-D Ig in a large inner-city emergency department (ED) over three years (July 2014 – June 2017). Indications for administration were scrutinised against current guidelines by experienced clinicians. Results: A total of 228 patients received anti-D Ig, with the majority being less than twelve weeks in gestation (169, 74.1%). Anti-D Ig was administered without support from the guidelines in 81 (35.5%) patients, with a lack of documented sensitising event in 77 (95%) of these cases. Discussion and Conclusion: There were inconsistencies amongst clinicians who prescribe anti-D Ig in the ED, and a lack of the application of current guidelines. This may stem from a lack of empirical evidence about the need for anti-D Ig in the most common group presenting to EDs, those under twelve weeks in gestation. Current guidelines also fail to take into consideration future need, which could be incorporated in future, ED specific anti-D Ig guidelines. Implications for research, policy, and practice: This audit identified overuse of anti-D Ig in the ED. This may stem from the absence of evidence for its use in pregnant patients under 12 weeks in gestation. To reduce unsupported use, further data on alloimmunisation rates following potentially sensitising events in early pregnancy would be helpful. Additional guidelines specific to patients under 12 weeks in gestation, and presenting to the emergency department may reduce some unsupported usage. What is already known about the topic? Pregnant patients who have an D-negative blood type are at risk of D alloimmunisation when a sensitising event occurs. It is common for patients to present to the emergency department with complications in early pregnancy Previous work has shown that there is variation in anti-D Ig administration in the emergency department. What this paper adds: There is significant use of anti-D Ig in the emergency department that is outside of current guidelines. The current guidelines may not serve the needs of the majority of presentations in the emergency department. Further data on alloimmunisation rates following potentially sensitising events in patients less then twelve weeks of gestation would be useful.

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients\u2019 perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany

BackgroundOnly few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends.MethodsThe follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial.ResultsFollow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged.ConclusionsMost patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients’ views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate.Trial registrationGerman Clinical Trials Register (DRKS00011930); date: 2017/04/25.

Incentive-Based Sexually Transmitted and Blood-Borne Infections Screening in High-Income Countries: A Systematic Review.

Despite increasing access to treatment and screening, rates of sexually transmitted and blood-borne infections (STBBI) continue to rise in high-income countries. The high cost of undiagnosed and untreated STBBI negatively affects individuals, health care systems, and societies. The use of monetary and nonmonetary incentives may increase STBBI screening uptake in high-income countries. Incentivized screening programs are most effective when developed specific to context and target population. Our review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion criteria were as follows: English language, high-income countries, primary research studies, and older than 16 years. Study quality was assessed using Joanna Briggs Institute quality assessment tools. The search yielded 6219 abstracts. Thirteen articles met the inclusion criteria. Studies took place in the United States, the United Kingdom, and Australia. Populations screened included: postsecondary and tertiary students, parolees or probationers, youth, and inner-city emergency department patients. Incentivized STBBI screened were human immunodeficiency virus (n = 5), chlamydia (n = 7), and multiple infections (n = 1). Incentives offered were monetary (cash/gift cards/not specified) (n = 10), nonmonetary (n = 1), and mixed (n = 2). Both monetary and nonmonetary incentives enhance STBBI screening in high-income countries. Incentivized screening programs are most effective when developed specific to context and target population. Further research is needed to analyze incentivized screening across similar study designs and to evaluate long-term effectiveness.

Clinical Characteristics of Anaphylaxis Cases in an Inner-City Pediatric Emergency Department (E.D.) in Brooklyn Over a 4 Year Period

Clinical Characteristics of Anaphylaxis Cases in an Inner-City Pediatric Emergency Department (E.D.) in Brooklyn Over a 4 Year Period

Differentiation of Individuals Previously Infected with and Vaccinated for SARS-CoV-2 in an Inner-City Emergency Department.

ABSTRACTEmergency departments (EDs) can serve as surveillance sites for infectious diseases. The objective of this study was to determine the burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to monitor the prevalence of vaccination against coronavirus disease 2019 (COVID-19) among patients attending an urban ED in Baltimore City. Using 1,914 samples of known exposure status, we developed an algorithm to differentiate previously infected, vaccinated, and unexposed individuals using a combination of antibody assays. We applied this testing algorithm to 4,360 samples from ED patients obtained in the spring of 2020 and 2021. Using multinomial logistic regression, we determined factors associated with infection and vaccination. For the algorithm, sensitivity and specificity for identifying vaccinated individuals were 100% and 99%, respectively, and 84% and 100% for previously infected individuals. Among the ED subjects, seroprevalence to SARS-CoV-2 increased from 2% to 24% between April 2020 and March 2021. Vaccination prevalence rose to 11% by mid-March 2021. Marked differences in burden of disease and vaccination coverage were seen by sex, race, and ethnicity. Hispanic patients, though accounting for 7% of the study population, had the highest relative burden of disease (17% of total infections) but with similar vaccination rates. Women and white individuals were more likely to be vaccinated than men or Black individuals. Individuals previously infected with SARS-CoV-2 can often be differentiated from vaccinated individuals using a serologic testing algorithm. The utility of this algorithm can aid in monitoring SARS-CoV-2 exposure and vaccination uptake frequencies and can potentially reflect gender, race, and ethnic health disparities.

Mental health conditions in older multimorbid patients presenting to the emergency department for acute cardiac symptoms: Cross-sectional findings from the EMASPOT study.

This study aimed to (1) examine the proportion of patients presenting to an emergency department (ED) for acute cardiac symptoms with comorbid mental health conditions (MHCs) comprising current depression, generalized anxiety disorder, and panic disorder; (2) compare cardiac patients with and without MHCs regarding sociodemographic, medical, and psychological characteristics; and (3) examine recognition and treatment rates of MHCs. Multimorbid patients, aged ≥50years, presenting to an inner-city ED with acute cardiac symptoms including chest pain, dyspnea, and palpitations, completed validated self-report instruments assessing MHCs and a questionnaire collecting psychosocial and medical information. In addition, routine medical data were extracted from the electronic health record. A total of 641 patients were included in the study. Mean (±SD) age was 68.8 (±10.8) years and 41.7% were female. Based on screening instruments, 28.4% of patients were affected with comorbid MHCs. Patients reported clinically significant symptoms of depression (23.3% PHQ-9≥10), generalized anxiety disorder (12.2% GAD-7≥10), and panic disorder (4.7% PHQ-PD). Patients with MHCs were more likely to be younger, female, lower educated, and unemployed. The presence of MHCs was associated with higher cardiac symptom burden and subjective treatment urgency as well as more psychosocial distress (PHQ-stress) and impaired quality of life (SF-12v2). Of all patients, 15.6% were identified with new or unrecognized MHCs. MHCs are prevalent in nearly one-third of patients presenting with cardinal cardiac symptoms. Thus, the ED visit offers an opportunity to identify and refer patients with MHCs to appropriate and timely care after exclusion of life-threatening conditions.

Evaluating Empiric Therapy for Acute Uncomplicated Cystitis in the Outpatient Setting: A Retrospective Cohort Study

ObjectivesTo evaluate the empiric therapy prescribed for acute uncomplicated cystitis in the outpatient setting (emergency department and ambulatory care clinics) and to characterize uropathogens for discordance between the therapy prescribed and susceptibility. MethodsA retrospective review was conducted at an inner-city emergency department and multiple clinics to evaluate the empiric therapy prescribed and the uropathogens isolated from culture for patients with acute uncomplicated cystitis. ResultsA total of 144 urine cultures were included. Among the patients, 53.4% were empirically prescribed cephalexin, 20.1% ciprofloxacin, 11% nitrofurantoin, and 8.3% trimethoprim/sulfamethoxazole. The most common uropathogen was Escherichia coli (72.4%), followed by Streptococcus agalactiae (7.6%) and Klebsiella pneumoniae (4.8%). Of the 107 E. coli isolates, 9 were extended spectrum beta-lactamase–producing. E. coli antimicrobial susceptibilities were as follows: ceFAZolin (97%), nitrofurantoin (96%), cefTRIAXone (91%), ciprofloxacin (87%), and trimethoprim-sulfamethoxazole (59%). The concordance rates with the Infectious Diseases Society of America treatment guidelines for acute uncomplicated cystitis and local resistance patterns were as follows: empiric therapy prescribed (70%), dosing of empiric therapy (77%), and duration of empiric therapy (22%). For empiric therapy prescribed and susceptibility mismatch, 5.6% of the isolates were not susceptible to therapy, 76.4% were susceptible to therapy, 14% did not have susceptibilities, and 4.2% did not receive therapy. ConclusionsMost of the cases of acute uncomplicated cystitis at the subject institution can be managed safely and effectively with nitrofurantoin or first-generation cephalosporins. Institutions should use national guidelines in conjunction with local resistance and prescribing patterns to improve antibiotic prescribing in the outpatient setting.

Caregiver Perceptions of Mental Health and Barriers to and Facilitators of Their Child's Treatment.

Nearly 1 million children visit emergency departments (EDs) annually for mental health crises. Caregivers play a critical role in the outcome of mental illness in their children, yet there is limited research on effective means to engage caregivers in the ED and provide the support they need. Our aim was to determine caregivers' perceptions about mental illness in their children, specifically regarding suicidality and depression, the impact of the children's mental health on the caregiver, and barriers to and facilitators of treatment. Guided by qualitative descriptive methodology, we conducted semistructured, open-ended interviews with a purposive sample of English-speaking primary caregivers of children 6 to 17 years old who presented with suicidal ideations or behaviors to 1 urban pediatric ED. Interviews were recorded and transcribed verbatim, and conventional content analysis was performed. The participants (n = 20) were largely single ethnic-racial minority mothers. Content analysis identified 6 categories: caregivers' definitions of mental health, depression, and suicidality; perceived causes of mental illness; difficulty in identification of mental illness; the influence of the mental illness on caregivers; a complex network of communication among involved parties that resulted in the child's ED visit, as well as barriers to and facilitators of treatment. We identified several categories that encapsulate caregivers' perceptions of mental health and mental illness in their children and its effect on them. Future research should explore how inner-city EDs might partner with schools and trusted community-based organizations to enhance caregiver knowledge, reduce obstacles to care, increase screening for at-risk youth and implement strategies to optimize outcomes for children with depression and suicidal ideations.

Patients' Perception of Telemedicine in a Large Urban Inner-City Emergency Department: A Cross-Sectional Survey.

IntroductionTelemedicine has the potential to ease emergency department (ED) overcrowding, improve ED throughput, and decrease the cost of medical care. Much of the current knowledge of telemedicine systems focuses on bringing more specialty care to the ED or improving access in rural areas. Limited research exists on patients’ perception of telemedicine in an urban ED.MethodsA survey exploring perceptions of telemedicine encounters was distributed to both providers and patients following mirrored encounters between October 2015 and August 2016. Chi-square analysis was conducted to identify associations between factors and openness to telemedicine from the patients’ perspective.ResultsA total of 174 patients were included in the analysis. Factors associated with patient willingness to try telemedicine included: having access to a tablet with internet (p=0.0023), having access to a tablet with camera (p=0.0025), having downloaded apps in the past (p=0.0028), having used an app in the past (p<0.0001), and had frequent video chat in the past (p=0.0142).ConclusionWith widespread access to smartphones with internet connectivity and pressing demands for healthcare services, telemedicine may provide a potential solution to low acuity medical care needs.

Homelessness, emergency care and mental health. Inner-city emergency department psychiatry referrals: a retrospective descriptive analysis.

Since the advent of COVID-19, the vulnerability of people who are homeless has come into sharper focus. The risk posed by sleeping rough or staying in emergency/temporary accommodation exposes homeless people to a high risk of transmission due to compromised access to isolation spaces and adequate hygiene facilities.

Food Insecurity and Insulin Use in Hyperglycemic Patients Presenting to the Emergency Department.

IntroductionThe prevalence of food insecurity (FI) and insulin rationing among patients with diabetes who present to the emergency department (ED) is unclear. We examined the prevalence of food insecurity and subtherapeutic insulin use among patients who presented to the ED with a blood glucose level of greater than 250 milligrams per deciliter.MethodsThis was a single-center, cross-sectional survey of clinically stable, hyperglycemic adults in the ED for food insecurity using the Hunger Vital Sign screening tool. Patients who were insulin dependent were asked about insulin usage and rationing.ResultsOf the 85 eligible patients, 76 (89.4%) were enrolled; 35 (46%) screened positive for food insecurity. Food insecure patients were 1.9 times more likely to be hospitalized than non-food insecure patients (relative risk = 1.90 [1.21–2.99], p<.01). Food insecure patients were younger than non-food insecure patients (50.4 vs 57.5 p<.02), and had significantly higher hemoglobin A1c (HgbA1c) levels (11.2% vs 9.9% p = 0.04). Of the 49 patients prescribed insulin, 17 (34.6%) stated they had used less insulin during the prior week than had been prescribed, and 21 (42.9%) stated they had used less insulin during the prior year than had been prescribed. Food insecure patients were more likely to have used less insulin than prescribed in the prior year (odds ratio = 3.60 [1.09–11.9], p = 0.04).ConclusionOur exploratory findings suggest almost half of clinically stable adults presenting to our inner-city ED with hyperglycemia experience food insecurity. More than one-third of those prescribed insulin used less than their prescribed amount in the prior year.

The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department.

Posttraumatic stress disorder (PTSD) symptoms and other negative psychosocial factors have been implicated in the transition from acute to persistent pain. Women (N = 375) who presented to an inner-city emergency department (ED) with complaints of acute pain were followed up for 3 months. They completed a comprehensive battery of questionnaires at an initial visit and provided ratings of pain intensity at the site of pain presented in the ED during 3 monthly phone calls. Latent class growth analyses were used to detect possible trajectories of change in pain intensity from the initial visit to 3 months later. A 3-trajectory solution was found, which identified 3 groups of participants. One group (early recovery; n = 93) had recovered to virtually no pain by the initial visit, whereas a second group (delayed recovery; n = 120) recovered to no pain only after 1 month. A third group (no recovery; n = 162) still reported elevated pain at 3 months after the ED visit. The no recovery group reported significantly greater PTSD symptoms, anger, sleep disturbance, and lower social support at the initial visit than both the early recovery and delayed recovery groups. Results suggest that women with high levels of PTSD symptoms, anger, sleep disturbance, and low social support who experience an acute pain episode serious enough to prompt an ED visit may maintain elevated pain at this pain site for at least 3 months. Such an array of factors may place women at an increased risk of developing persistent pain following acute pain.

Exploring the common prescribing errors that occur in the emergency department.

Prescribing errors are a subset of medication errors that occur on the forms used to prescribe medicines for patients. On their discharge from the emergency department (ED), many patients are given a prescription form to obtain medicines from their local community pharmacist. On the identification of a prescribing error, the patient is sent back to the ED because the medicine cannot be dispensed. To identify the most common prescribing errors on prescriptions returned to one large inner-city ED in South Wales from community pharmacies. Prescriptions that were returned to the ED over a six-week period from September and October 2016 were analysed to determine the types of prescribing errors that occurred and their frequency. A total of 10,218 patients attended the ED over the six-week period, of which 7,731 patients were seen by a clinician and discharged home. Of these, 322 patients were discharged with a prescription, and 20 (6%) of these patients returned to the ED with a prescribing error that prevented the pharmacist from dispensing the medicines. The most common prescribing error was incorrect or missing prescriber information. This study identified that there was a low rate of prescribing errors in the ED, and this was comparable with the rate of prescribing errors identified in the literature. Common prescribing errors could be mitigated through the introduction of electronic prescribing in the ED.

Patiromer for Treatment of Hyperkalemia in the Emergency Department: A Pilot Study.

Hyperkalemia is common and potentially life threatening. Patiromer is a Food and Drug Administration (FDA)-cleared oral potassium binder effective in the chronic treatment of hyperkalemia. The objective was to investigate the potential efficacy and safety of oral patiromer in treating acute hyperkalemia in the emergency department (ED). This is a single-center, randomized, open-label convenience sample pilot study in an inner-city ED. Adult patients with end-stage renal disease and a serum potassium level of≥6.0mEq/L were randomized to standard of care (SOC) or one dose of 25.2g oral patiromer plus SOC (PAT). Blood samples and electrocardiograms were collected at enrollment and at 1, 2, 4, and 6hours thereafter. The primary outcome was the difference in potassium between groups at 6hours. Secondary outcomes were the amount and number of times insulin and albuterol were given. Thirty patients were included in the final analysis, 15 in each group. There were no differences in age, sex, or baseline serum potassium. There was no difference in mean serum potassium between SOC and PAT groups at 6hours (6.32mEq/L, confidence interval [CI]= 6.0 to 6.63mEq/L vs. 5.81mEq/L, CI= 5.48 to 6.14mEq/L). However, 2hours posttreatment the serum potassium of the PAT group was lower than SOC group (5.90mEq/L, CI= 5.63 to 6.17mEq/L vs. 6.51mEq/L, CI= 6.25 to 6.78mEq/L) and also 0.61mEq/L lower than baseline. There were no differences in the amount or number of administrations of insulin or albuterol between groups, although the amount of albuterol used in the PAT group at 6hours was lower but not significant (median, 0mg vs. 12.5mg; p=0.097). There were no differences in adverse events between groups. In this open-label pilot study of severe hyperkalemia, a single dose of 25.2g of oral patiromer reduced serum potassium within 2hours but did not show a difference at 6hours. This is the first study showing that patiromer may have a role in the acute management of hyperkalemia; however, more rigorous studies are needed.

Maybe It's Time to Rethink Freestanding Emergency Departments.

Maybe It's Time to Rethink Freestanding Emergency Departments.