Medical Center Emergency Department Research Articles

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging.

Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI. A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis. Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis. Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (). Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.

Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study

BackgroundComputed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results.MethodsThis three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results.ResultsIn total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98–4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings.ConclusionChief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

Pediatric Epistaxis-Effectiveness of Conservative Management.

Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management. This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018. Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population. Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

The Lipid Intensive Drug Therapy for Sepsis Phase II Pilot Clinical Trial.

Low cholesterol levels in early sepsis patients are associated with mortality. We sought to test if IV lipid emulsion administration to sepsis patients with low cholesterol levels would prevent a decline or increase total cholesterol levels at 48 hours. Phase II, adaptive, randomized pilot clinical trial powered for 48 patients. Emergency department or ICU of an academic medical center. Sepsis patients (first 24 hr) with Sequential Organ Failure Assessment greater than or equal to 4 or shock. Patients meeting study criteria, including screening total cholesterol levels less than or equal to 100 mg/dL or high-density lipoprotein cholesterol (HDL-C) + low-density lipoprotein cholesterol (LDL-C) less than or equal to 70 mg/dL, were randomized to receive one of three doses of lipid emulsion administered twice in 48 hours or no drug (controls). The primary endpoint was a change in serum total cholesterol (48 hr - enrollment) between groups. Forty-nine patients were enrolled and randomized. Two patients randomized to lipid emulsion were withdrawn before drug administration. Data for 24 control patients and 23 lipid emulsion patients were analyzed. The mean change in total cholesterol from enrollment to 48 hours was not different between groups and was 5 mg/dL (sd 20) for lipid emulsion patients, and 2 mg/dL (sd 18) for control patients (p = 0.62). The mean changes in HDL-C and LDL-C were similar between groups. Mean change in triglycerides was elevated in lipid emulsion patients (61 mg/dL, sd 87) compared with controls (20 mg/dL, sd 70, p = 0.086). The 48-hour change in SOFA score was -2 (interquartile range [IQR] -4, -1) for control patients and -2 (IQR -3, 0) for lipid emulsion patients (p = 0.46). Administration of IV lipid emulsion to early sepsis patients with low cholesterol levels did not influence change in cholesterol levels from enrollment to 48 hours.

Diagnosis of Fever Source Following Tonsillectomy and Adenoidectomy in the Pediatric Emergency Department.

This study aimed to describe the epidemiology and diagnoses of children with postoperative fever (a temperature of 38°C or higher) during the week after tonsillectomy and/or adenoidectomy and to assess the yield of the laboratory tests and otolaryngologist consultations of these patients in the pediatric emergency department (ED). We conducted a retrospective cohort study that included all children who presented with fever to the pediatric ED of a tertiary university-affiliated medical center between May 2017 and April 2020 during the week after a tonsillectomy and/or adenoidectomy. There were 94 patients who fulfilled study entry criteria during the 3-year study period, representing a 6% rate of postoperative fever for combined tonsillectomy and adenoidectomy and 3% for adenoidectomy alone. Only 9 patients (<10% of the total) were classified as having bacterial infection, whereas the most common cause for the fever was pneumonia diagnosed by chest radiography. None had surgical site infection. There was no significant difference in blood test findings of patients diagnosed with a bacterial infection and patients with a presumed viral infection or an inflammatory response to surgery. The results of this investigation revealed that the source of fever of the overwhelming majority of children who were referred to the pediatric ED for fever after undergoing tonsillectomy and/or adenoidectomy was pneumonia as determined by chest radiography, which can be performed in an outpatient setting. Blood tests and otolaryngologist consultations were not contributory in classifying the source of fever, questioning the value of their routine use in these patients.

The epidemiological characteristics of pediatric head injury in Hangzhou, China: a retrospective study based on cranial CT examinations

ABSTRACT Primary objective This study aims to create a pediatric head injury database based on cranial CT examinations and explore their epidemiologic characteristics. Methods Data related to cranial CT examinations of pediatric head injuries from March 2014 to March 2021 were collected at outpatient and emergency department of a pediatric medical center. The causes of injury, observable post-injury symptoms, and cranial injury findings were extracted with the assistance of natural language processing techniques. Results Reviewing the data from records on 52,821 children with head injuries over a period of 7 years, the most common causes of pediatric head injury were falls (58.3%), traffic accidents (26.0%), smash/crush/strike (13.9%), violence (1.5%) and sports-related incidents (0.3%). Overall, most of those injured were boys which accounting for 62.2% of all cases. Skull fractures most commonly occur in the parietal bone (9.0%), followed by the occipital (5.2%), frontal (3.3%) and temporal bones (3.0%). Most intracranial hemorrhages occurred in epidural (5.8%), followed by subdural (5.1%), subarachnoid (0.9%), intraparenchymal (0.5%) and intraventricular (0.2%) hemorrhages. Spring and autumn showed more events than any other season. Conclusions To the best of our knowledge, this is the largest sample of epidemiological study of head injury in the Chinese pediatric population to date.

Real-Time Tracheal Ultrasound vs. Capnography for Intubation Confirmation during CPR Wearing a Powered Air-Purifying Respirator in COVID-19 Era.

This study aimed to compare the accuracy of real-time trans-tracheal ultrasound (TTUS) with capnography to confirm intubation in cardiopulmonary resuscitation (CPR) while wearing a powered air-purifying respirator (PAPR). This setting reflects increased caution due to contagious diseases. This single-center, prospective, comparative study enrolled patients requiring CPR while wearing a PAPR who visited the emergency department of a tertiary medical center from December 2020 to August 2022. A physician performed the TTUS in real time and recorded the tube placement assessment. Another healthcare provider attached waveform capnography to the tube and recorded end-tidal carbon dioxide (EtCO2) after five ventilations. The accuracy and agreement of both methods compared with direct laryngoscopic visualization of tube placement, and the time taken by both methods was evaluated. Thirty-three patients with cardiac arrest were analyzed. TTUS confirmed tube placement with 100% accuracy, sensitivity, and specificity, whereas capnography demonstrated 97% accuracy, 96.8% sensitivity, and 100% specificity. The Kappa values for TTUS and capnography compared to direct visualization were 1.0 and 0.7843, respectively. EtCO2 was measured in 45 (37-59) seconds (median (interquartile range)), whereas TTUS required only 12 (8-23) seconds, indicating that TTUS was significantly faster (p < 0.001). No significant correlation was found between the physician's TTUS proficiency and image acquisition time. This study demonstrated that TTUS is more accurate and faster than EtCO2 measurement for confirming endotracheal tube placement during CPR, particularly in the context of PAPR usage in pandemic conditions.

Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates

ObjectivesIn the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time. MethodsWe conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021–June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends. ResultsThe response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%–39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%–100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%–91%). Eighty-five percent (95% CI, 77%–92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%–85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%–23%) report an average of 1 complication annually. ConclusionsAll programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

A Retrospective Analysis of Intravenous Insulin versus Insulin and Nebulized Albuterol for the Treatment of Hyperkalemia in the Emergency Department.

There is limited literature evaluating the use of nebulized albuterol in the management of hyperkalemia. The objective was to evaluate the efficacy of insulin alone compared with the addition of nebulized albuterol for the treatment of hyperkalemia. This is a retrospective, single-center evaluation of adult patients with hyperkalemia attending the Emergency Department of a large urban academic medical center. Consecutive patients with a potassium level of >5mmol/L were included. Patients without a repeat potassium level within 4hours of medication administration, those receiving hemodialysis before a repeat serum potassium, or those that had a hemolyzed blood sample were excluded. The primary outcome was the change in potassium level within 4hours in patients who received insulin monotherapy versus patients who received insulin and albuterol. The secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, and mortality. Out of the 204 patients, 141 received insulin, whereas 63 received insulin and nebulized albuterol. There was no difference in the change in potassium level between the insulin and the insulin and nebulized albuterol groups (0.85±0.6 vs 0.96±0.78mmol/L; P=.36). There was no difference in median hospital length of stay (8.6days, IQR13.2days, vs 5.6days, IQR8.2days; P=.09), ICU admission (31.9% vs 38.1%; P=.39), and all-cause mortality (14.9% vs 17.5%; P=.64). In this retrospective analysis, the addition of albuterol to insulin for the treatment of hyperkalemia did not result in a greater change in potassium level within 4hours of therapy.

Descriptive evaluation of patients receiving one-time intravenous vancomycin doses at a large academic medical center emergency department

BackgroundIntravenous (IV) vancomycin is commonly used to treat a variety of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). The practice of administering a single dose of IV vancomycin prior to emergency department (ED) discharge may be clinically ineffective and foster antimicrobial resistance. Furthermore, this practice introduces an unnecessary infection risk along with preventable adverse effects while potentially increasing ED length of stay (LOS). There is a paucity of literature identifying patient characteristics and objective findings in this patient population, which may foster future antimicrobial stewardship initiatives in the ED. MethodsThis was a single-center, retrospective, descriptive analysis of adult patients seen in the ED between January 2020 and January 2023 who received a single dose of IV vancomycin and were subsequently discharged from the ED without hospital admission. Information was collected on patient demographics and select comorbidities, vancomycin indication and dosing, ED LOS, initial vitals and labs, concomitant antibiotics administered, culture results, 30-day return ED visits and admissions, and antibiotics prescribed at ED discharge. ResultsA total of 295 patients met inclusion criteria. A total of 32.1% of patients met SIRS criteria. The most commonly selected order indication for IV vancomycin was “skin and skin structure infection” (41%). A total of 86.1% of patients received concomitant antibiotics in the ED and only 54.6% of patients were prescribed oral antibiotics at ED discharge. A total of 80% of patients had at least one culture obtained during the ED visit. In those who had at least one culture obtained, 78.4% of patients had negative cultures and 4.2% of patients had MRSA positive cultures, with MRSA skin cultures being the most common (3.1%). Return ED visits and admissions within 30 days were not statistically significantly different between patients who did and did not receive oral antibiotics at ED discharge. ConclusionsDespite a lack of clinical efficacy reported in prior literature and the potential risks, administration of a one-time dose of IV vancomycin prior to ED discharge is commonly encountered in clinical practice. There are opportunities for enhanced antimicrobial stewardship related to IV vancomycin use in the ED. Areas of future focus include the utilization of oral antimicrobials when clinically appropriate, particularly for skin and soft tissue infections, and clarification of antibiotic allergies.

Outcomes of Vaso-Occlusive Episode Management in Adults Vs. Pediatrics in the Emergency Department

Introduction: Vaso-occlusive episodes (VOEs) contribute to significant morbidity and mortality in patients with sickle cell disease (SCD) and require timely treatment. Prompt intravenous fluids (IVF) and analgesics are key mainstays of care that may influence outcomes such as the increased disease burden from VOE-associated tissue infarction and the development of chronic pain. VOEs often lead to uncontrolled pain, requiring frequent ED (emergency department) visits and hospitalizations. Timely acute care management is crucial for curbing the significant polymerization of hemoglobin (Hgb) S and dehydration, which increases sickling of Hgb and can precipitate VOEs. In this study, we investigate the relationship between variables such as time to first IVF and IV pain medications in the ED for adult and pediatric patients with SCD presenting with VOEs and rates of admission. Methods: A retrospective study was conducted to analyze outcomes of adult and pediatric patients with SCD at Loma Linda University Medical Center ED and Children's Hospital ED. Patients with HgbSS, HgbSC, and HgbS/beta-thalassemia genotypes with at least two encounters at our institution for VOEs were included. Endpoints collected were time to first IVF in the ED, time to first IV pain medication, and rate of admission. Two-sample Wilcoxon rank-sum (Mann-Whitney) test was utilized to compare time to first IVF or pain medication in adult vs pediatric patients and the rates of admission. In these models, age, gender, and genotype were adjusted for. Results: 110 patients, 56 adult and 54 pediatric, with a total of 298 patient encounters were analyzed. In the adult population, 55% were male and 45% were female, with a median age of 30. In the pediatric population, 56% were male and 44% were female, with a median age of 10. Of the patients, 47 adult and 43 pediatric patients had severe genotypes (HgbSS or HgbS/beta-thalassemia). Compared to the adult population, the pediatric group had lower odds of receiving IVF and IV pain medications in &amp;lt; 90 minutes (min) of presentation to the ED (odds ratio (OR): 0.13, p=0.01 &amp; OR: 0.114, p=0.02, respectively), controlling for age, gender, and genotype. There was no significant difference in the median time to first IVF or IV pain medication in adults compared to pediatric patients (p=0.22 and p=0.42, respectively) (Table 1). When comparing adult and pediatric patients who received IVF and IV pain medications in &amp;lt; 90 min vs ≥ 90 min, the rates of admission were lower in the &amp;lt; 90 min groups (rates of admission by time to IVF: 56.9% for ≥ 90 min vs 51.8% for &amp;lt; 90 min in adults &amp; 62.4% for ≥ 90 min vs. 50.1% for &amp;lt; 90 min in pediatric patients; rates of admission by time to IV pain medications: 60.9% for ≥ 90 min vs 12.5% for &amp;lt; 90 min in adults &amp; 60.8% for ≥ 90 min vs 50.5% for &amp;lt; 90 min in pediatric patients) (Table 2). Conclusion: Overall, shorter time to IVF and IV pain medications in the ED led to decreased rates of admission for both adult and pediatric patients, regardless of age, gender, or genotype. Despite higher odds of adults receiving IVF and IV pain medications in &amp;lt; 90 min compared to pediatric patients, there was no difference in median time to IVF or IV pain medications. Thus, developing protocols to decrease the time to IVF and pain medications in the adult and pediatric ED setting may subsequently lead to improved outcomes for patients with SCD. The study calls for larger studies to further elucidate the significance of time to initial IVF and IV pain medications in the acute management of VOEs.

Bridging the gap: a qualitative study of providers' perceptions of a partnered crisis follow-up program for suicidal patients post-emergency department discharge

BackgroundEffective interventions are needed to address suicide risk following discharge from the hospital emergency department or inpatient setting. Studies that examine follow-up contact methods show promise, but little is known about how follow-up programs are implemented in the real world and who is benefitting. The purpose of this formative evaluation and analysis was to gain insight about the usefulness and value of a partnered suicide prevention follow-up program (academic medical center emergency department partnered with a regional suicide prevention center) from the standpoint of psychiatry resident physicians providing direct care and suicide prevention center crisis counselors making follow-up outreach telephone calls to patients.MethodsA qualitative thematic analysis was conducted with focus group data from a convenience sample of psychiatry residents who performed consultations in the emergency department setting and counselors at the suicide prevention center crisis follow-up program. Focus group sessions, using semi-structured question guides, were completed at each participant group’s workplace. Grounded theory techniques were used to guide coding and analytic theme development.ResultsAnalyses resulted in four overarching themes: valuing the program’s utility and benefit to patients, desiring to understand what happens from emergency department discharge to program follow-up, having uncertainty about which patients would benefit from the program, and brainstorming to improve the referral process. Psychiatry residents appreciated the option of an “active” referral service (one that attempts to actively engage a patient after discharge through outreach), while suicide prevention crisis counselors valued their ability to offer a free and immediate service that had potential for fostering meaningful relationships. Both participant groups desired a better understanding of their partner’s program operations, a uniform and smooth referral process, and awareness of who may or may not benefit from program services.ConclusionResults revealed the need for improved communication and implementation, such as expanded inter-agency contacts, consistent provider training, more documentation of the requirements and rules, a consistent message about program logistics for patients, and coordination between the program elements.

PEAL Score to Predict the Mortality Risk of Cardiogenic Shock in the Emergency Department: An Observational Study.

The in-hospital mortality of cardiogenic shock (CS) remains high (28% to 45%). As a result, several studies developed prediction models to assess the mortality risk and provide guidance on treatment, including CardShock and IABP-SHOCK II scores, which performed modestly in external validation studies, reflecting the heterogeneity of the CS populations. Few articles established predictive scores of CS based on Asian people with a higher burden of comorbidities than Caucasians. We aimed to describe the clinical characteristics of a contemporary Asian population with CS, identify risk factors, and develop a predictive scoring model. A retrospective observational study was conducted between 2014 and 2019 to collect the patients who presented with all-cause CS in the emergency department of a single medical center in Taiwan. We divided patients into subgroups of CS related to acute myocardial infarction (AMI-CS) or heart failure (HF-CS). The outcome was all-cause 30-day mortality. We built the prediction model based on the hazard ratio of significant variables, and the cutoff point of each predictor was determined using the Youden index. We also assessed the discrimination ability of the risk score using the area under a receiver operating characteristic curve. We enrolled 225 patients with CS. One hundred and seven patients (47.6%) were due to AMI-CS, and ninety-eight patients among them received reperfusion therapy. Forty-nine patients (21.8%) eventually died within 30 days. Fifty-three patients (23.55%) presented with platelet counts < 155 × 103/μL, which were negatively associated with a 30-day mortality of CS in the restrictive cubic spline plot, even within the normal range of platelet counts. We identified four predictors: platelet counts < 200 × 103/μL (HR 2.574, 95% CI 1.379-4.805, p = 0.003), left ventricular ejection fraction (LVEF) < 40% (HR 2.613, 95% CI 1.020-6.692, p = 0.045), age > 71 years (HR 2.452, 95% CI 1.327-4.531, p = 0.004), and lactate > 2.7 mmol/L (HR 1.967, 95% CI 1.069-3.620, p = 0.030). The risk score ended with a maximum of 5 points and showed an AUC (95% CI) of 0.774 (0.705-0.843) for all patients, 0.781 (0.678-0.883), and 0.759 (0.662-0.855) for AMI-CS and HF-CS sub-groups, respectively, all p < 0.001. Based on four parameters, platelet counts, LVEF, age, and lactate (PEAL), this model showed a good predictive performance for all-cause mortality at 30 days in the all patients, AMI-CS, and HF-CS subgroups. The restrictive cubic spline plot showed a significantly negative correlation between initial platelet counts and 30-day mortality risk in the AMI-CS and HF-CS subgroups.

Abstract 18827: Emergency Department Threat Perceptions and PTSD Symptoms After Suspected Stroke

Introduction: Stroke is a leading cause of death, physical, and psychological disability in the United States. One in four stroke survivors develop significant PTSD symptoms (PTSS), which can influence disease outcomes. It is important to identify factors that increase early psychological distress and subsequent PTSS development, such as threat perceptions in the emergency department (ED). Understanding the relationship between ED threat and PTSS may help identify areas for improving early stroke care. The purpose of this study was to determine whether ED threat perceptions influence PTSS development at 1-, 6- and 12-months after suspected stroke. Methods: The sample consisted of patients (n = 203, 48% female, 59.4 ± 15.5 years) who presented to the ED of an academic medical center for suspected stroke. ED threat was assessed in-hospital using the ED Threat Perceptions questionnaire, and PTSS were assessed at 1-, 6- and 12- months post-stroke using the PCL-5 tool. Linear regression was used to assess the association between ED threat and PTSD symptoms, adjusting for demographics, depression, chronic disease severity (Charlson index), and stroke severity (NIHSS). Results: In unadjusted analyses, ED threat perceptions were associated with higher PTSS at 1- (β=0.42, 95% CI [0.16-0.68] p=0.002), 6- (β=0.32, 95% CI [0.07-0.58], p=0.013), and 12-mo (β=0.44, 95% CI [0.15-0.72], p=0.003), independent of demographics, stroke severity, and depressive symptoms when expressed continuously. In nested models, addition of ED threat perceptions to a model including demographics and stroke severity significantly improved the model (Δ-2 log likelihood = 7.15, df=1; p=0.007), indicating independent effects in the association of ED threat perceptions with PTSD symptoms beyond stroke severity. Conclusions: ED threat perceptions were associated with higher PTSS at 1-, 6-, and 12-months after suspected stroke even after accounting for clinician-measured stroke severity. This suggests that early threat perceptions contribute to PTSD risk above and beyond the physical impact of the event. These results indicate the importance of the ED environment and provide a target for future interventions to minimize the development of PTSD symptoms post-stroke.

Pediatric injury attendances in different population groups in Israel before, during, and after COVID-19 lockdowns: a descriptive study, 2018–2022

BackgroundLockdowns and quarantines during the COVID-19 pandemic influenced healthcare services’ usage patterns such as emergency department (ED) attendance. During the pandemic, Israel issued three lockdowns (March–May 2020, September–October 2020, and December 2020–February 2021) to mitigate the spread of COVID-19. Little is known about the impact of these lockdowns on ED attendance for injuries in the diverse population of Northern Israel.MethodsWe described patterns of ED attendance before, during, and after COVID-19 lockdowns. We extracted data from medical records of all northern Israeli children aged 0–17 years old who attended Ziv Medical Center (ZMC) emergency department (ED) due to injury, between 01/01/2018 and 10/02/2022. We compared the volume and characteristics of ED attendance during lockdown periods to the same time periods in the 2 years before the pandemic and 1 year after the lockdowns, using chi-square tests.ResultsSeven thousand six hundred nineteen northern children attended ZMC ED during the time periods of the study for injuries and were analyzed. Mean attendance numbers during lockdowns decreased compared to previous years, with an increase in injuries proportion (67.8% (1502/2216) vs. 52.7% (2038/3868) p < 0.001). The proportion of 0–4-year-olds attending for injuries during the lockdown increased compared to pre-pandemic (39.68% vs. 30.7%, p < 0.0001). Minority population attendance decreased (27.47% vs. 30.71% p = 0.02). Hospitalization rates increased (13.21% vs. 10.65% p = 0.01). Post-lockdown periods saw a return to the pre-pandemic age and ethnicity distribution.ConclusionsCompared to previous years, the volume of injuries was lower during lockdowns for all ages, with a relative increase in the proportion of injuries among younger children attending the ED. A lower proportion of attendance from minority groups suggests different health-seeking behavior patterns during emergencies compared to the general population. Understanding these differences will help better plan for future emergencies.

Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors.

Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.

Naloxone prescriptions among patients with a substance use disorder and a positive fentanyl urine drug screen presenting to the emergency department

BackgroundOver 109,000 people in the USA died from a drug overdose in 2022. More alarming is the amount of drug overdose deaths involving synthetic opioids other than methadone (SOOM), primarily fentanyl. From 2015 to 2020, the number of drug overdose deaths from SOOM increased 5.9-fold. SOOM are commonly being found in many other drugs without the user's knowledge. Given the alarming number of overdose deaths from illicit drugs with SOOM, naloxone should be prescribed for all persons using illicit drugs regardless of if they knowingly use opioids. How often providers prescribe naloxone for these patients remains unknown.The aim of this study is to determine the rate of naloxone prescriptions given to patients with any substance use disorder, including when the patient has a urine drug screen positive for fentanyl. Secondary aims include determining what patient factors are associated with receiving a naloxone prescription.MethodsThe design was a single-center retrospective cohort study on patients that presented to the Augusta University Medical Center emergency department between 2019 through 2021 and had an ICD-10 diagnosis of a substance use disorder. Analyses were conducted by logistic regression and t-test or Welch’s t-test.ResultsA total of 10,510 emergency department visits were by 6787 patients. Naloxone was prescribed in 16.3% of visits with an opioid-related discharge diagnosis and 8.4% of visits with a non-opioid substance use-related discharge diagnosis and a urine drug screen positive for fentanyl. Patients with a fentanyl positive urine drug screen had higher odds of receiving a naloxone prescription (aOR 5.80, 95% CI 2.76–12.20, p < 0.001). Patients with a psychiatric diagnosis had lower odds of being prescribed naloxone (aOR 0.51, p = 0.03). Patients who received naloxone had a lower number of visits (mean 1.23 vs. 1.55, p < 0.001). Patients with a urine drug screen positive for cocaine had higher odds of frequent visits (aOR 3.07, p = 0.01).ConclusionsFindings should remind providers to prescribe naloxone to all patients with a substance use disorder, especially those with a positive fentanyl urine drug screen or a co-occurring psychiatric condition. Results also show that cocaine use continues to increase healthcare utilization.

Differences in Risks for Recurrent Injury and Death Among Survivors of Violence by Homeless Status.

A better understanding of the unique risks for survivors of violence experiencing homelessness could enable more effective intervention methods. The aim of this study was to quantify the risks of death and reinjury for unhoused compared to housed survivors of violent injuries. This retrospective study included a cohort of patients with known housing status presenting to the Boston Medical Center Emergency Department between 2009 and 2018 with a violent penetrating injury. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the risks of all-cause mortality and violent reinjury. Of the 2330 patients included for analysis, 415 (17.8%) were unhoused at the time of index injury. Within 3years of the index injury, there were 319 (13.9%) violent reinjuries and 55 (2.4%) deaths. Unhoused patients were more likely than housed patients to be violently reinjured by all causes (HR = 1.39, 95% CI = 1.06-1.83, p = 0.02), by stab wound (HR = 2.34, 95% CI = 1.33-4.11, p = 0.0003), and by blunt assault (HR = 1.52, 95% CI = 1.05-2.21, p = 0.03). Housed and unhoused patients were equally likely to die within 3years of their index injury; however, unhoused patients were at greater risk of dying by homicide (HR = 2.89, 95% CI = 1.34-6.25, p = 0.006) or by a drug/alcohol overdose (HR = 2.86, 95% CI = 1.17-6.94, p = 0.02). In addition to the already high risks that all survivors of violence have for recurrent injuries, unhoused survivors of violence are at even greater risk for violent reinjury and death and fatal drug/alcohol overdose. Securing stable housing for survivors of violence experiencing homelessness, and connecting them with addiction treatment, is essential for mitigating these risks.

Disparities in use of physical restraints at an urban, minority-serving hospital emergency department.

Recent reports have identified associations between patient race and ethnicity and use of physical restraint while receiving care in the emergency department (ED). However, no study has assessed this relationship in hospitals primarily treating patients of color and underserved populations. The primary objective of this study was to evaluate the association between race/ethnicity and the use of restraints in an ED population at a minority-serving, safety-net institution. For this cross-sectional study, chart review identified all adult patients presenting to the Boston Medical Center ED between January 2018 and April 2021. Generalized estimating equation logistic regression modeling was conducted to evaluate associations between race and use of restraints. Of 348,384 ED visits (22.9% White, 46.7% Black, 23.1% Hispanic), 1852 (0.5%) had an associated physical restraint order. Multivariable models showed significant interactions (p = 0.02) between race/ethnicity, behavioral health diagnosis, and sex on the primary outcome of physical restraint. Stratified analysis revealed that among patients with no behavioral health diagnoses, Black (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.72, p = 0.0003) and Hispanic (OR 0.35, 95% CI 0.20-0.63, p = 0.0004) patients had lower odds of restraint than White patients. Among female patients with a mental health and/or substance use disorder diagnosis, Black (OR 1.95, 95% CI 1.49-2.54, p < 0.0001) and Hispanic (OR 2.13, 95% CI 1.49-3.03, p < 0.0001) patients had higher odds of restraint than White patients. Similar trends were observed for Black male patients (OR 1.60, 95% CI 1.34-1.91, p < 0.0001) but not for Hispanic male patients (OR 0.96, 95% CI 0.73-1.26, p = 0.77) with behavioral health diagnoses who had similar odds of restraint to White patients. Additional factors associated with physical restraint include younger age, public or lack of insurance, and ED visits during the pandemic. Racial disparities exist in restraint utilization at this minority-serving safety-net hospital; however, these disparities are modified by sex and by behavioral health diagnoses. The reasons for these disparities may be multifactorial and warrant further investigation.

Predictors of intensive care unit admission in adult cancer patients presenting to the emergency department with COVID-19 infection: A retrospective study.

Adult cancer patients with COVID-19 were shown to be at higher risk of Intensive Care Unit (ICU) admission. Previously published prediction models showed controversy and enforced the importance of heterogeneity among different populations studied. Therefore, this study aimed to identify predictors of ICU admission (demographic, clinical, and COVID-19 targeted medications) in cancer patients with active COVID-19 infection presenting to the Emergency Department (ED). This is a retrospective cohort study. It was conducted on adult cancer patients older than 18 years who presented to the American University of Beirut Medical Center ED from February 21, 2020, till February 21, 2021, and were found to have COVID-19 infection. Relevant data were extracted from electronic medical records. The association between different variables and ICU admission was tested. Logistic regression was done to adjust for confounding variables. A p-value less than 0.05 was considered significant. Eighty-nine distinct patients were included. About 37% were admitted to the ICU (n = 33). Higher ICU admission was seen in patients who had received chemotherapy within one month, had a respiratory rate at triage above 22 breaths per minute, oxygen saturation less than 95%, and a higher c-reactive protein upon presentation to the ED. After adjusting for confounding variables, only recent chemotherapy and higher respiratory rate at triage were significantly associated with ICU admission. Physicians need to be vigilant when taking care of COVID-19 infected cancer patients. Patients who are tachypneic at presentation and those who have had chemotherapy within one month are at high risk for ICU admission.