Local Community Hospital Research Articles

The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents.

The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents.

Variables affecting complication rates in type III paediatric supracondylar humerus fractures.

PurposeUnstable supracondylar humerus (SCH) fractures may have different outcomes as a result of direction of displacement and pin configuration. This study evaluates the impact of fracture displacement, pin configuration and fellowship training on clinical and radiographic outcomes in unstable fractures.MethodsA total of 99 patients with completely displaced type III fractures were identified at an academic centre and a local community hospital. Patient characteristics and the fellowship training of the treating surgeon were recorded, and injury films documented the direction of displacement. Pin configuration, coronal and sagittal alignment were recorded from postoperative radiographs and at healing. Radiographic outcomes including coronal, sagittal and rotational malunion as well as clinical complications were analyzed.ResultsFractures with direct posterior displacement had a lower composite malunion rate compared with those with posterolateral (PL) or posteromedial (PM) displacement (6.9%, 36.4%, 29.2% respectively; p = 0.019). PM displacement had a higher rate of coronal malunion compared with PL (18.2% versus 0%; post hoc p = 0.024). All-lateral constructs resulted in more rotational malunions (20.9% versus 1.8%; p = 0.002) compared with crossed pinning. PL fractures treated with all-lateral fixation showed a trend toward increased rotational instability or malunion (23.8% versus 1.3%; p = 0.073). Higher composite complication rates were noted in patients treated by surgeons with non-paediatric, non-trauma fellowship training.ConclusionFor displaced SCH fractures, all-lateral fixation is associated with higher rates of rotational instability and malunion. Posteromedially and posterolaterally displaced fractures have higher rates of malunion compared with fractures with straight posterior displacement. Fellowship training other than paediatric or trauma was associated with increased complications.Level of EvidenceLevel III

63 Topical Use of Tranexamic Acid in the Emergency Department

The usage of topical TXA has been shown in certain cases of epistaxis to reduced time to stop bleeding, rates of rebleeding, time spent in the emergency department and increased patient satisfaction. Local administration of topical TXA has since been described in various settings in emergency medicine journals. This study seeks to evaluate the use of tranexamic acid as a medication for the management of epistaxis and other superficial hemorrhages in the emergency department (ED) of local community hospitals. Retrospective review of adult ED patients from two community hospitals presenting with epistaxis or other superficial hemorrhage, treated with topical tranexamic acid (TXA) and discharged home between 2016 and 2019. Excluded from the study are traumatic nose injuries, major trauma patients, post-operative patients, and patients with incomplete data. Abstracted data included demographics, chief complaints, discharge diagnosis, history of anticoagulant use, outcome of TXA use, and 72 hours return to the ED with recurrent hemorrhage. Data analysis was performed on the index cases only. Demographics and outcomes are reported as descriptive statistics. Significance is set at 0.05 for comparison between anti-coagulation groups. There were 341 cases meeting inclusion criteria. Ten cases were excluded with four nasal trauma, three post-operative cases, and three with missing data. Nineteen case were patients returning within 72 hours, leaving 312 index cases. There were 192 cases of epistaxis and 120 cases of cutaneous (81) or mucosal (39) wounds. Overall, 48.4% of the patients were on outpatient anti-coagulants with 7.7% on two medications. The 72-hour return rate was 5.8% with 6.8% in the epistaxis group and 4.2% in the superficial wound group. Outpatient anti- coagulation did not affect 72 hours returns in epistaxis (6.5% versus 7.1%; p=0.856) but was significant in superficial wounds (11.6% return in anti-coagulant group versus 0%; p=0.002). In this four-year study of topical tranexamic acid use in two community emergency departments, 48.4% of the patients were on outpatient anti-coagulants. The 72-hour return rate for epistaxis was 6.8% and not affected by anti-coagulant use while the return rate for superficial wounds was 4.2% and impacted by anti-coagulant use. Epistaxis and superficial wound treated in the emergency department with topical tranexamic acid have a small return rate for hemorrhage control, despite outpatient anti-coagulant use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Contracts to Coordinate Healthcare Providers in the Telemedicine Referral System

With the help of telemedicine, healthcare providers can increase patients’ access to high-quality services while reducing the medical expenditure, especially for patients in remote areas. Once advanced care is needed, local patients will first be referred to an online health service and then be referred to the offline hospital if the online healthcare fails. In practice, local community hospitals and the advanced tertiary hospitals generally lack financial incentives to exert costly, but non-reimbursable, effort to avoid poor patient outcomes. Therefore, we build a new model to analyze the interaction between these two service providers, promoting them to exert the right effort by designing payment contracts. Our results show that neither fee-for-service nor bundled payment contracts can achieve the social optimum. Tertiary hospitals always exert less effort than the socially-optimal effort while the community hospital may exert less or more effort depending on the online treatment cost. Then, we propose a performance-based bundled payment contract that can coordinate both hospitals’ decisions to achieve socially optimal outcomes. Finally, we numerically show the impact of the referral service fee and the online treatment cost on the efficiency of these contracts.

The Use of Electronic Health Record Systems During COVID-19 at a Local Community Hospital on the West Coast

The United States Federal government looks toward information technology to curtail health care costs while increasing the quality of patient care through the adoption of electronic health record (EHR)systems. This paper examined the experience of a hospital with its EHR system in the context of the pandemic. Results showed that the hospital maintains a state-of-the-art health care system to provide quality care to its community and was responsive to the recent crisis. The results were consistent with other comparable hospitals examined in this study. The hospitals were successful in adopting EHR systems. They were able to identify gaps that could be filled with technology add-ons from different software vendors to improve their functionality and thereby provide better & timely patient care. Managing large volumes of data generated in the normal process of EHR operation and ensuring data privacy and security were the significant challenges faced and are likely to continue in the future.

Narrative review of congenital lung lesions.

This article reviews the contemporary diagnosis and management of antenatally diagnosed congenital lung lesions. These anomalies, which include congenital pulmonary airway malformation (CPAM) (formerly congenital cystic adenomatoid malformation), bronchopulmonary sequestration (BPS), bronchogenic cyst, and congenital lobar emphysema (CLE), are relatively rare but are increasingly encountered by clinicians because of the improved resolution and enhanced sensitivity of fetal ultrasound. Serial assessment of these lesions throughout pregnancy remains the norm rather than the exception. Perinatal management strategies may differ based on initial size and growth patterns of these masses until delivery. Fetal magnetic resonance imaging and other diagnostic testing can sometimes be helpful in providing additional prognostic information. Over the last decade, maternal steroids have become standard of care in the management of larger lesions at risk for nonimmune hydrops. As a result, fetal surgical procedures, including open resection, thoracoamniotic shunting, and ex utero intrapartum treatment (EXIT), are less uncommonly performed. Decisions regarding whether delivery of these fetuses should occur in a tertiary care center with pediatric surgery coverage versus delivery at a local community hospital are now highly relevant in most prenatal counseling discussions with families. Large lung malformations may require urgent surgical removal in the early postnatal period because of respiratory distress. Other complications, such as recurrent pneumonia, pneumothorax, and cancer, are indications for postnatal lung resection on an elective basis. Many children are good candidates for minimally invasive (thoracoscopic) surgical approaches as an alternative to resection by thoracotomy. In the vast majority of cases, the overall prognosis remains excellent.

Tiger Trauma

A 40-year-old woman presents to the trauma bay after being mauled by a tiger. She was emergently transported to the local tertiary community hospital for stabilization and treatment. She suffered from 33 different lacerations of multiple puncture wounds across her chest, full thickness lacerations to her left and posterior neck, left posterior scalp, and left arm. Vitals were stable and GCS 15. She was able to move all extremities with some weakness to her LUE and right sided facial droop with ptosis. She was subsequently intubated for distress, potential airway decompensation, and possible carotid artery injury. CT imaging illustrated a stable spinous process fractures at C5 and C6, non-displaced fractures of the left transverse process at C7 and T1, extensive subcutaneous emphysema within the inferior neck, superior right chest, and left clavicular region, as well as, air within the cervical canal and extrinsic to the thecal sac. MRI suggested ligamentous strain in the posterior longitudinal ligament at the C2-3 level, small amount of paraspinal hemorrhage on the left C2-3, within the interspinous ligaments C3-7 and marked edema/hemorrhage within the trunks and divisions of the left brachial plexus highly suspicious for brachial plexus injury. ENT and neurosurgeon diagnosed right facial palsy and began dexamethasone treatment. ID physician tailored antibiotics to vancomycin for human skin flora and ampicillin/sulbactam for Pasteurella multocida from the tiger. She was to switch to doxycycline, amoxicillin/clavulanate, and wound care after discharge. She was transferred for reconstructive surgery for the brachial plexus injury, electromyography, and electroneuronography testing.

86 Reducing Inappropriate Readmissions From A Community Hospital—A Quality Improvement Project

Abstract Introduction Quality person-centred care in those approaching the end of life includes consideration and anticipation of their preferred place of death and ceiling of care (CoC). This QI project to reduce inappropriate readmissions was prompted following the transfer of a palliative patient to the acute trust from a community hospital. Method Data was collected from the electronic patient record (EPR) at weekly intervals over a six month period, July to December. Electronic documentation of CoC from 507 records from a 24 bed community hospital was reviewed. Data collected included patient age, sex and whether a CoC decision entry had been made on the EPR during the community hospital inpatient stay. The appropriateness of readmissions over the same period was also analy sed. A weekly consultant geriatrician ward round was introduced focusing on advanced care planning with explicit decision making regarding preferred place of care. Results There were a total of 16 readmissions during the study period. 3 of these were deemed “inappropriate” following EPR review occurring in August, September and October. Subsequent review of electronic CoC July to October inclusive demonstrated a median completion rate of 20.5%. Following intervention there were no further inappropriate readmissions and the median CoC completion rate was 85%. Qualitatively, the consultant geriatrician managing the community hospital felt there had been a cultural shift where staff felt more comfortable managing complex palliative care. Conclusions Introduction of a weekly Consultant Geriatrician ward round in the community setting has led to a sustained improvement in CoC decision-making and documentation. As a result of this there have been no further inappropriate readmissions to the acute trust. This reflects the national guidance in patient centred palliative care. Further work including robust, qualitative assessment of staff attitude towards palliative care is needed to emulate this work at other local community hospitals.

159 Utility of universal preadmission COVID-19 testing in labor and delivery unit at local community hospital

To estimate prevalence of asymptomatic SARS-CoV-2 positive pregnant (carriers) through universal preadmission L&D screening at local community hospitals system located in northwest Ohio and southeast Michigan. Retrospective cohort analysis of universal COVID-19 testing in pregnant was performed at ProMedica Health care system from March to September 2020 during COVID-19 pandemic. During COVID-19 pandemic our health care elected to follow universal preadmission L&D screening and universal use of PPE strategy aimed to protect healthcare workers and prevent spread of new coronavirus infection. It was believed that pregnant women are at higher risk for COVID-19 as compared to general population. All scheduled term pregnant patients underwent universal nasopharyngeal COVID-19 qRT-PCR 48 hours prior to delivery. Positive patients were triaged over the phone for symptoms. Positive patients were identified as asymptomatic, mild, moderate, severe or critical disease according to SMFM guidelines. 2357 deliveries occurred during study timeframe, out of which 1399 pregnant patients (59.4%) were eligible for universal testing. Among 1399 pregnant who were scheduled for preadmission L&D SARS-CoV-2 screening, 1165 (83.3%) underwent testing prior to scheduled hospital admission, 202 (14.4%) delivered prior to scheduled test and 32 (2.3%) patient declined testing. Out of 1165 screened, 10 (0.9%) were tested SARS-CoV-2 positive. Two out of 1165 (0.2%) developed mild symptoms and 8 (0.7%) were asymptomatic. 1155 (99.1%) were tested SARS-CoV-2 negative (Fig.1). The estimated prevalence of SARS-CoV-2 carriers among scheduled for L&D admission in ProMedica Health care system were 0.7% from March to August 2020. This carrier rate is almost similar to general population rate in Ohio (1.2%)2 and Michigan (1.2%)2 during both surges in cases (Fig. 2). Based on our small cohort, it appears that COVID-19 carrier rate is similar between pregnant and general population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Implementation of a pharmacist-led transitions of care program in an indigent care clinic: A randomized controlled trial

ObjectivesPharmacists’ involvement in the transitions of care has shown the potential to decrease readmissions and increase access to care in many populations; however, the uninsured patient populations have not been studied. The evidence for the feasibility of implementing transitions of care services in indigent care clinics with limited resources also remains limited. The objectives were to implement a pharmacist-led transitions of care program in an indigent care clinic, to demonstrate the feasibility of its implementation, and to evaluate its impact on readmissions and emergency department (ED) visit rates among an uninsured population. MethodsThe study was a single-blind, parallel, randomized controlled trial implemented in an indigent care clinic in the Southeast region of the United States from October 2018 to July 2019. Eligible patients were those older than 18 years, uninsured, English-speaking, diagnosed with any condition, and recently discharged from a local community hospital within the past 16 days. The primary outcome was the hospital readmission rate at 30 days after discharge. The secondary outcomes included 60- and 90-day readmission rates in addition to 30-, 60-, and 90-day ED visit rates. ResultsA total of 88 participants were recruited. The intervention was successfully implemented in the clinic, but patient-level barriers to follow-ups included transportation, accessibility, financial burdens, inconsistent telephone communication, and a lack of knowledge about the importance of follow-ups. At 30 days postdischarge, 13.64% of the patients in the usual care group experienced readmissions compared with 9.30% of the patients in the intervention group. The relative change in the 30-day readmission rates between the usual care and the intervention groups was 1.7 (rate ratio [RR] 1.69 [95% CI 0.47–6.08]). The RRs were insignificant for the 30-, 60-, and 90-day readmission and ED visit rates. ConclusionThis study demonstrated the feasibility of implementing transitions of care services in a clinic with limited resources by pharmacists. The intervention showed promising results by reducing readmission rates.

Informing the development of a transitions of care program between an emergency department and regional supermarket chain pharmacies

ObjectivesPharmacist collaboration in transitions of care (TOC) programs is integral to increase patient education and adherence after discharge. This study aimed to conduct a qualitative evaluation of stakeholder perspectives to inform the design and implementation of a TOC program between an emergency department (ED) and regional supermarket chain pharmacies. MethodsPharmacies from a regional supermarket chain were identified for inclusion on the basis of geographic proximity to a local community hospital ED. Semistructured, one-on-one interviews with the primary investigator were conducted. Interview questions were based on the Consolidation Framework for Implementation Research (CFIR). The following 5 CFIR domains were used: (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) characteristics of individuals, and (5) process. Interviews were audio-recorded and transcribed. Two investigators coded each transcript independently. A thematic analysis was performed. ResultsA total of 19 interviews were conducted, and the following 7 major themes emerged on analysis: (1) enhance real-time interprofessional communication, (2) establish data sharing between the ED and the community pharmacy, (3) provide timely resolution of prescription insurance issues for new therapies post-ED discharge, (4) use off-site pharmacy resources to support community pharmacy workflow, (5) increase patient education to prevent primary medication nonadherence, (6) reinforce discharge care plans, and (7) focus on community-dwelling older adult patients in an ED care transition program. ConclusionHealth care providers including pharmacists, physicians, nurses, and care managers, view an ED-to-community pharmacy TOC program as a valuable service to increase patient education on new medications and discharge planning. Establishment of data sharing and reimbursement is integral to the development, implementation, and sustainability of such programs. There is an untapped opportunity for community pharmacists to bridge the gap in care after ED discharge.

Hepatitis B Virus Infection Prevalence among Patients in a Local Community Hospital in Nasarawa State, Nigeria

Hepatitis B Virus Infection Prevalence among Patients in a Local Community Hospital in Nasarawa State, Nigeria

Rapid Treatment of Acute Ischemic Stroke Using a Computed Tomography-Based Reperfusion Protocol: The Reality of a Local Community Hospital with Limited Resources.

In patients with acute ischemic stroke (AIS), prognosis strongly depends on the onset-to-recanalization time. The Ishinomaki protocol for rapid recanalization has been used since October 2017. This protocol determines the indication for reperfusion therapy based on computed tomography (CT)/three-dimensional CT angiography (3DCTA) findings and intends to reduce the onset-to-recanalization time. We aimed to compare the outcomes before and after protocol introduction. Our hospital is the only thrombectomy-capable center in Ishinomaki, Tome, and Kesennuma medical area. Before protocol introduction (April 2014-June 2016), both CT and magnetic resonance imaging were performed to determine the indications for intravenous (IV) recombinant tissue-plasminogen activator (rt-PA) or mechanical thrombectomy within 6 hours of disease onset. However, after protocol introduction (from October 2017), plain CT and 3DCTA were used. We collected data on patients who underwent mechanical thrombectomy and/or IV rt-PA before (n = 13) and after (n = 34) the protocol introduction. The required time from onset to door (OTD), door to needle (DTN), needle to puncture (NTP), puncture to recanalization (PTR), and door to recanalization (DTR) were compared before and after protocol introduction. Furthermore, thrombolysis in cerebral infarction (TICI) grades and modified Rankin scale (mRS) scores at discharge were compared. The outcomes before and after protocol introduction were as follows: OTD: 105 ± 73.8 (mean ± standard deviation) vs. 120 ± 68.1 min (p = 0.376, Mann-Whitney U test); DTN: 62.9 ± 15.9 vs. 41 ± 17 min (p <0.01); NTP: 112 ± 69.8 vs. 39.9 ± 33.7 min (p <0.01); PTR: 87.9 ± 45.4 vs. 52.5 ± 27.9 min (p <0.01); and DTR, 230 ± 69.9 vs. 110 ± 40.3 min (p <0.0001). Before and after protocol introduction, the proportion of patients with TICI grade 2b-3, mRS score of 0-2 at discharge, and mRS score of 5-6 were 54% vs. 50% (p = 0.815, Fisher's exact test), 23% vs. 21% (p = 0.854), and 15% vs. 50% (p = 0.046), respectively. The Ishinomaki protocol reduced the mean DTR time by 120 min. The reduction in treatment time was due to the change in CT-based recanalization and collaboration with emergency physicians and paramedics. There was no increase in good outcomes, but there was a significant increase in poor outcomes at discharge. Patients who could not be salvaged were indicated for reperfusion therapy as CT and 3DCTA cannot detect the ischemic core.

Déjà Vu - A New Coronavirus Challenge.

Déjà Vu - A New Coronavirus Challenge.

AI-guided resource allocation and rescue decision system for medical applications

With the robust growth in the social environment, millions of families have vast medical plans nowadays. Each client requires a personalized medical rescue decision, making an intelligent recommendation system highly important. In practice, wealthy families tend to purchase tailored medical services, while others tend to seek medical services from local community hospitals. Noticeably, trillions-scale of medical service transactions occurs daily, making the development of a fully automatic intelligent recommendation system to match the suitable medical services to clients urgent. In this work, we propose a novel Internet-scale deep architecture that automatically recommends personalized and tailored medical rescue services based on the previously discovered clients with different financial tolerance. Specifically, given a massive number of client families, first, we create a set of features that represents the multiple medically related attributes of each family. These features capture the income, health status, type of diseases, occupation, and so on. The features are then combined into a descriptive feature by multi-view learning, which can dynamically assign the importance of each feature channels. Based on the combined feature, affinity graphs are created on a large scale to represent the relations between the client families. Also, an efficient dense subgraph mining is used to categorize the million-scale clients into 10 different medical groups. Finally, various customized medical services can be tailored for each client in a fully automatic and efficient manner. Comprehensive experiments on our collected data sets demonstrated the competitiveness of our proposed intelligent recommendation system. Moreover, the results of visualized dense subgraph mining showed that the client families with different wealth levels can be distinguished accurately.

Minimal Population Prevalence and Mortality of Coronavirus Disease 2019 in Healthcare Personnel.

Among 3926 healthcare personnel in a multisite healthcare system, the minimal population prevalence of coronavirus disease 2019 (COVID-19) was 4.4% (bootstrap 95% confidence interval [CI], 3.7%–5.0%), and the infection fatality rate was 0.6% (bootstrap 95% CI, 0.0%–1.7%). Rates reflected both local community prevalence and hospital exposures but not specifically exposure on COVID-19 units.

Abstract PO-034: A collaborative approach to increase germline testing and counseling uptake within New York City’s underserved patient population

Abstract Background: Understanding the role of genetic drivers in cancer is a fundamental component of precision medicine. Further, identification of germline mutations provides important clinical data for patients. Understanding the risk conferred by inheriting certain mutations can guide treatment and screening behaviors for both patients and their family members. Despite the importance of testing, minority patients are less likely to undergo germline testing. Patient and physician reported barriers include limited or no knowledge of genetic tests, limited knowledge of hereditary cancer syndromes, lack of educational materials, time constraints, lack of genetic counselors, and out-of-pocket costs. Objective: To describe how an academic-community collaboration between local healthcare institutions addresses some known barriers to germline testing and counseling in a typically underrepresented patient population. Methods: The Cancer Health Equity Research Program (CHERP) at Memorial Sloan Kettering (MSK) partners with local community hospitals, which serve diverse populations, to provide somatic and germline testing to their cancer patients under the research protocol, MSK-IMPACT™ (Integrated Mutation Profiling of Actionable Cancer Targets). Testing and counseling are provided by the Center for Molecular Oncology and Clinical Genetics Service at MSK. Site clinicians are trained on study procedures to ensure they are prepared to educate their patients on the purpose of genetic testing. Non-clinical MSK research staff (NCMRS) are trained as consenting professionals and delegated to a site to address clinic time constraints. NCMRS facilitate the collection, shipment, and tracking of biospecimens and collaborate with MSK’s Clinical Genetics Service on behalf of the sites. To address both educational and language barriers, a subtitled video on germline testing, translated informed consents, and translated educational brochures are provided to each site. Results: Since March 2018, 270 patients from our CHERP sites agreed to germline testing. Self-reported race is as follows: 35 Asian (13.0%), 123 Black (45.6%), 25 Caucasian (9.3%), 1 Pacific Islander (0.4%), 11 Other (4.1%), and 75 Unknown (27.8%). Additionally, 99 (36.7%) patients identified as Hispanic and Hispanics represent 90.7% of self-reported Unknown race and 100% of the self-reported Other race. Of the 270 patients, 201 have had successful germline testing (62 patients ineligible and 7 pending results) with 26 (12.9%) having a positive finding. Genetic counseling was provided for 17 (65.4%) of these patients, with 6 sessions in-person and 11 telegenetic sessions. Conclusion: Disparities in genetic testing are well documented and efforts to expand access to testing and counseling for minority patients are urgently needed. In partnership with local hospitals, CHERP addresses many of the barriers that contribute to these disparities and demonstrated success in providing germline testing and counseling for minority patients. Citation Format: Kenya P. Vado, Thomas Reynolds, Kellie Jack, Linda Bulone, Margaret Kemeny, Jason Gonsky, Lewis Kampel, Shadai Mcmillan, Anna Maio, Margaret Sheehan, Erin Salo-Mullen, Sandy Naupari, Jesse Galle, Alisha Williams, Zsofia Stadler, Mark Robson, David Solit, Paul Sabbatini, Carol Brown. A collaborative approach to increase germline testing and counseling uptake within New York City’s underserved patient population [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-034.

Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department.

ObjectivesAssess the impact of an electronic health record (EHR)‐embedded clinical pathway (ePATH) as compared to a paper‐based clinical decision support tool on outcomes for patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS).MethodsA retrospective, quasi‐experimental study using difference‐in‐differences and interrupted time series specifications to evaluate the impact of an EHR‐embedded clinical pathway between April 2013 and July 2017. The intervention was implemented in February 2016 at a large academic tertiary hospital and compared to a local community hospital without the intervention. Eligible patients included adults (>18 years) presenting to the ED with chest pain who had a troponin ordered within 2 hours of arrival and a chest pain‐related diagnosis. Patients with initial evidence of acute myocardial infarction were excluded. Primary outcomes included rates of admission and stress testing, hospital length of stay, and occurrence of major adverse cardiac events.ResultsOn average, there were 170 chest pain visits per month at the intervention site. The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after ePATH implementation. After comparison with the comparator site, ePATH was still associated with a significant reduction in hospital admissions (‐10.79%, P < 0.001) and stress testing (‐6.05%, P < 0.001). Hospital length of stay and rates of major adverse cardiac events did not significantly change.ConclusionsImplementation of ePATH for patients presenting to the ED with chest pain was associated with safe reductions in hospital admission and stress testing. ePATH appears to be an effective tool for implementing evidence‐based guidelines for ED patients with chest pain.

Association between participation in hospital-led community activities and sense of security in continued community living among older adults in a rural district of Japan: A cross-sectional study.

For older adults to continue living in a community, they need to have a certain sense of security, especially in terms of the availability of healthcare in the community. The aim of this cross-sectional study was to explore important factors of the sense of security among older adults in their continued community living, with particular attention to hospital-led community activities. The participants comprised 252 randomly sampled older adults aged 65years or older, living in a local community in western Japan, and ranging from being independent to physically and cognitively frail. Participants' sense of security in continued community living was assessed using a modified scale from past research on cancer care. Activities provided by local community organisations and hospitals were examined. The participants' mean age was 75.0years, 144 (57.8%) were female and 32 (13.3%) were frail. Hospital-led groups (e.g. health lectures) and individual (e.g. health counselling) activities were used by 73 (30.5%) and 76 (31.9%) participants respectively. Among participants, 174 (73.4%) had participated in activities run by the local community, such as senior day celebrations or senior centre activities. A stronger sense of security was associated with participation in hospital-led individual activities (β=0.171, p=.036), being a member of a neighbourhood association (β=0.156, p=.020), frequency of contact with family members (β=0.145, p=.034) and lower depression (β=-0.269, p<.001). Participation in community hospital-led individual activities may provide older adults opportunities to discuss their health-related concerns in a community setting, and thus might enhance their sense of security. In the aged society, the role of healthcare facilities may need to be expanded to facilitate outreach for older adults in the community to enhance their sense of security and actualise ageing in place.

The Role of Emergency Medical Services in the Opioid Epidemic

The opioid crisis is an ongoing public health concern and EMS agencies are in a critical position to reach at-risk populations. The traditional role of EMS in treating acute opioid overdoses has expanded to include preventative strategies as well as long-term treatment and recovery options. EMS agencies are uniquely positioned to partner with local community resources and hospitals to combine efforts in implementing harm-reduction strategies.