Multiple Emergency Department Research Articles

Understanding uptake of information about innovations among emergency department clinicians during the COVID-19 pandemic.

Early in the COVID-19 pandemic, little was known about managing sick patients, but emergency department (ED) clinicians had to decide which treatments and care processes to adopt. Our objective was to describe how ED clinicians learned about innovations and how they assessed them for credibility during the pandemic. We purposively sampled clinicians from hospital-based EDs to conduct focus groups with ED clinicians and staff. We used both inductive and deductive approaches to conduct thematic analysis of transcripts. We conducted focus groups with clinicians from eight EDs across the United States. We found that ED clinicians in our sample relied on friends and colleagues or departmental and institutional leadership for information on innovations. They used social media sources when they came from credible accounts but did not directly seek information from professional societies. Clinicians reported a range of challenges to obtain credible information during the pandemic, including a fractured and changing information environment, policies misaligned across clinical sites or that conflicted with clinical knowledge, high patient volume, fear of harming patients, and untimely information. Facilitators included access to experienced and trusted colleagues and leaders and practicing at multiple EDs. Participants cited anecdotal evidence, institutional practice, and word-of-mouth-rather than peer-reviewed evidence and professional society communications-as their primary sources of information about care innovations during the early phases of the pandemic. These results underscore the importance of developing trusted local mechanisms and wider networks to identify and vet information for frontline clinicians during rapidly emerging public health emergencies.

Ethnicity and outcomes for patients with gastrointestinal disorders attending an emergency department serving a multi-ethnic population

BackgroundEthnic inequalities in acute health acute care are not well researched. We examined how attendee ethnicity influenced outcomes of emergency care in unselected patients presenting with a gastrointestinal (GI) disorder.MethodsA descriptive, retrospective cohort analysis of anonymised patient level data for University Hospitals of Leicester emergency department attendees, from 1 January 2018 to 31 December 2021, receiving a diagnosis of a GI disorder was performed. The primary exposure of interest was self-reported ethnicity, and the two outcomes studied were admission to hospital and whether patients underwent clinical investigations. Confounding variables including sex and age, deprivation index and illness acuity were adjusted for in the analysis. Chi-squared and Kruskal–Wallis tests were used to examine ethnic differences across outcome measures and covariates. Multivariable logistic regression was used to examine associations between ethnicity and outcome measures.ResultsOf 34,337 individuals, median age 43 years, identified as attending the ED with a GI disorder, 68.6% were White. Minority ethnic patients were significantly younger than White patients. Multiple emergency department attendance rates were similar for all ethnicities (overall 18.3%). White patients had the highest median number of investigations (6, IQR 3–7), whereas those from mixed ethnic groups had the lowest (2, IQR 0–6). After adjustment for age, sex, year of attendance, index of multiple deprivation and illness acuity, all ethnic minority groups remained significantly less likely to be investigated for their presenting illness compared to White patients (Asian: aOR 0.80, 95% CI 0.74–0.87; Black: 0.67, 95% CI 0.58–0.79; mixed: 0.71, 95% CI 0.59–0.86; other: 0.79, 95% CI 0.67–0.93; p < 0.0001 for all). Similarly, after adjustment, minority ethnic attendees were also significantly less likely to be admitted to hospital (Asian: aOR 0.63, 95% CI 0.60–0.67; Black: 0.60, 95% CI 0.54–0.68; mixed: 0.60, 95% CI 0.51–0.71; other: 0.61, 95% CI 0.54–0.69; p < 0.0001 for all).ConclusionsSignificant differences in usage patterns and disparities in acute care outcomes for patients of different ethnicities with GI disorders were observed in this study. These differences persisted after adjustment both for confounders and for measures of deprivation and illness acuity and indicate that minority ethnic individuals are less likely to be investigated or admitted to hospital than White patients.

Symptomatic Gallbladder Stones: From Occasional to Everyday in Pediatric Surgery

Introduction: Gallbladder stones (GS) in children were once considered rare. In recent years, the rate of cholecystectomies appears to have increased. GS may present with symptoms in 60% of cases and can be simple GS (biliary colic) or complicated GS (cholecystitis, pancreatitis, choledocholithiasis). Laparoscopic cholecystectomy (LC) is the treatment of choice. The disease often leads to multiple emergency department visits and even hospitalizations, generating an increase in morbidity and public health costs. The objective of this study is to evaluate the clinical presentation, risk factors, complications, treatment, and evolution of GS in children. Materials and Methods: Retrospective, cross-sectional study in children from 0 to 14 years of age, who underwent cholecystectomy for symptomatic GS at the Hospital Nacional Prof. A. Posadas between January 2018 and July 2022 (54 months). Results: A total of 219 LCs were performed, 36 (2018), 39 (2019), 36 (2020), 62 (2021) and 47 (first half of 2022) in patients with a mean age of 12.3 years (3-14), 68% female, 25% overweight, 23% obese, 86 patients with family GS. 36% complicated GS (CGS); 29 patients presented cholecystitis, 26 choledochal syndrome, and 33 pancreatitis. 15% had 3 or more consultations prior to surgery and 12% began as biliary colic and later presented CGS. 62% of patients with cholecystitis presented microlithiasis as an ultrasound finding and 88% of patients with pancreatitis presented microlithiasis. ERCP was required in 17 patients, IOC in 6 (2.7%), Rendez Vous in 3 (1.37%). 21 patients (9%) with postoperative complications were reported, of which 1 required relaparotomy. Conclusions: The incidence of GS has increased considerably in the period studied. The data suggest that poor diet and family GS are factors to be considered in its development. Finally, the time of evolution and the delay in surgical resolution has led to a higher prevalence of CGS in our population, which is why we believe that patients with symptomatic GS should be operated on after diagnosis.

Point-of-Care Ultrasound in the Emergency Department: Training, Perceptions, Applications, and Barriers from Different Healthcare Professionals.

Point-of-care ultrasound (POCUS) is a valuable tool that assists in diagnosis and management of patients in the emergency department (ED) while being cost-efficient and without the use of ionizing radiation. To discern the opinions and perceptions of ED staff about POCUS applications and barriers, we conducted a cross-sectional survey of employees of 12 EDs in North Texas. Participants completed a 20-item online survey about POCUS with questions pertaining to four domains: (1) employee and training information, (2) perceived benefits, (3) common applications, and (4) barriers to use. Out of 805 eligible ED employees, 103 completed the survey (16.1% response rate). The results indicated a generally positive perception of POCUS among all employee types. Physician had significant exposure and training of POCUS than non-physician group ( p < 0.001). Physicians tend to find cardiac assessments more useful for clinical management than non-physicians (47% vs. 23%, p = 0.01), while non-physicians find soft tissue/abscess assessments more useful (27% vs. 9%, p = 0.01). The most significant barriers to POCUS use were time constraints for physicians and a lack of training for non-physician employees. Our study provides valuable insights into the perceptions of multiple ED professionals, serving as a foundation for promoting POCUS use in the ED.

Abstract PO1-10-03: Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients

Abstract Background: Social determinants of health (SDOH), the non-medical factors that influence health status, have a profound impact on breast cancer (BC) outcomes and contribute to survival disparities. Food insecurity (FI), defined as a lack of consistent access to adequate food resources, is a modifiable SDOH associated with treatment disruptions, medication nonadherence, and decreased quality of life. To identify at-risk patients and inform future interventions, we implemented SDOH screening of patients seen in breast oncology clinic at our urban academic medical center. Methods: Screening was conducted through an 8-item questionnaire on the electronic patient portal. The questions covered FI, housing and transportation challenges, and emergency department (ED) visits. We conducted a retrospective analysis of SDOH data collected among patients scheduled for a breast oncology appointment between 11/1/22 and 5/25/23. Any level of food hardship or concern constituted a positive FI screen. Descriptive statistics were used to determine the prevalence of FI and other SDOH, to assess differences in FI rates by age, race/ethnicity, and clinical stage, and to compare characteristics of food-insecure vs food-secure patients. We also conducted a multivariable logistic regression analysis to estimate the odds ratio (OR) and 95% confidence interval (CI) associated with sociodemographic/clinical factors and FI. Results: A total of 2,585 patients were seen in our breast oncology practice, of which 1,189 (46.0%) were screened for SDOH, including 41.2% non-Hispanic White (NHW), 9.6% non-Hispanic Black (NHB) and 21.0% Hispanic patients. Among patients who responded to each SDOH question, 15.5% (146/940) reported some level of FI; 8.7% (84/962) were unable to pay their rent or mortgage on time; for 5.8% (57/989), lack of transportation interfered with their treatment. The FI rate differed significantly by race and ethnicity: 4.5% of NHW, 15.2% of NHB, and 41.8% of Hispanic patients reported FI (p&amp;lt; 0.001). In multivariable analysis, NHB and Hispanic patients also had significantly higher odds of FI compared to NHW patients (OR=3.68, 95% CI=1.7-7.7, p&amp;lt; 0.001 for NHB and OR=15.0, 95% CI=8.8-27.1, p&amp;lt; 0.001 for Hispanic patients). Patients with metastatic disease had higher rates of FI compared to other breast oncology patients (23.6% vs 14.8%, p=0.048), and a metastatic BC diagnosis was associated with over twice the odds of FI (OR=2.18, 95% CI=1.1-4.2, p=0.02). Among food-insecure patients, 41.1% were unable to pay their rent or mortgage on time and 22.6% reported transportation difficulties interfering with treatment (vs 2.6% and 2.4%, respectively, for food-secure patients (p&amp;lt; 0.001)). Compared to food-secure patients, those who were food-insecure had significantly higher rates of self-reported ED visits in the past 12 months: 18.8% vs. 33.6% reported at least 1 ED visit, respectively, and 5.2% vs. 16.4% reported multiple ED visits, respectively (p&amp;lt; 0.001). Conclusions: In this analysis of SDOH data among patients seen in breast oncology clinic, FI was the most common social health risk reported, with nearly a quarter of patients with metastatic BC reporting FI. Racial/ethnic minorities were also at considerably higher risk for FI. ED utilization was significantly higher among food-insecure patients. Targeted interventions to reduce FI in at-risk populations are warranted to improve clinical and healthcare utilization outcomes. Sociodemographic and Clinical Characteristics and Other Reported Social Determinants of Health Among Food-Secure vs Food-Insecure Patients Citation Format: Claire Sathe, David DeStephano, Anita Gul, Melissa Beauchemin, Justine Kahn, Melissa Accordino, Katherine Crew, Ngozika Emezienna, Dawn Hershman. Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-10-03.

Socially vulnerable patients are more likely to fail outpatient management of symptomatic cholelithiasis

BackgroundSymptomatic cholelithiasis is a common surgical problem, with many patients requiring multiple gallstone-related emergency department (ED) visits before cholecystectomy. The Social Vulnerability Index (SVI) identifies vulnerable patient populations. This study aimed to assess the association between social vulnerability and outpatient management of symptomatic cholelithiasis. MethodsPatients with symptomatic cholelithiasis–related ED visits were identified within our health system from 2016 to 2022. Clinical outcomes data were merged with SVI census track data, which consist of 4 SVI subthemes (socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation). Multivariate analysis was used for statistical analysis. ResultsA total of 47,292 patients presented to the ED with symptomatic cholelithiasis, of which 6103 patients (13.3 %) resided in vulnerable census tract regions. Of these patients, 13,795 (29.2 %) underwent immediate cholecystectomy with a mean time to surgery of 35.1 h, 8250 (17.4 %) underwent elective cholecystectomy at a mean of 40.6 days from the initial ED visit, and 2924 (6.2 %) failed outpatient management and returned 1.26 times (range, 1–11) to the ED with recurrent biliary–related pain. Multivariate analysis found social vulnerability subthemes of socioeconomic status (odds ratio [OR], 1.29; 95 % CI, 1.09–1.52) and racial and ethnic minority status (OR, 2.41; 95 % CI, 2.05–2.83) to be associated with failure of outpatient management of symptomatic cholelithiasis. ConclusionSocially vulnerable patients are more likely to return to the ED with symptomatic cholelithiasis. Policies to support this vulnerable population in the outpatient setting with timely follow-up and elective cholecystectomy can help reduce delays in care and overutilization of ED resources.

Factors associated with repeat emergency department visits for mental health care in adolescents: A scoping review

ObjectivesThe aim of this review was to identify factors associated with multiple visits to emergency department (ED) services for mental health care in adolescents. MethodsElectronic databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and ProQuest Dissertations & Thesis Global) were searched for evidence that presented an association between risk factors or correlates of multiple visits to the emergency departmental for mental health care by 10–24 year olds. High impact use was defined as at least one return ED visit for mental health care. Primary studies of any quantitative design were included, with no exclusions based on language or country and all possible risk factors were considered. Data were extracted and synthesised using quantitative methods; frequencies of positive, negative and null associations were summarised for categories of potential risk factors. ResultsSixty-five studies were included in the review. Most studies were from North America and reported a wide range of measures of high impact ED use, the most common being a binary indicator of multiple ED visits. Sex/gender and age were the most frequently reported risk factors. Measure of previous or concurrent access to mental health care was consistently positively associated with high impact use. Having private health insurance, compared with public or no insurance, was generally negatively associated with high impact use. Proxy measures of socioeconomic position (SEP) showed associations between lower SEP and more high impact use in a small number of studies. No other factors were consistently or uniformly associated with high impact use. ConclusionsThe review identified a substantial evidence base but due to the variability in study design and measurement of both risk factors and outcomes, no consistent risk factors emerged. More research is needed, particularly outside North America, using robust methods and high quality routinely collected data.

Predictive factors of basic palliative and hospice care among patients with cancer visiting the emergency department in a Hungarian tertiary care center

IntroductionPatients with advanced cancer tend to utilize the services of the health care system, particularly emergency departments (EDs), more often, however EDs aren't necessarily the most ideal environments for providing care to these patients. The objective of our study was to analyze the clinical and demographic characteristics of advanced patients with cancer receiving basic palliative care (BPC) or hospice care (HC), and to identify predictive factors of BPC and HC prior to their visit to the ED, in a large tertiary care center in Hungary. MethodsA retrospective, detailed analysis of patients receiving only BPC or HC, out of 1512 patients with cancer visiting the ED in 2018, was carried out. Sociodemographic and clinical data were collected via automated and manual chart review. Patients were followed up to determine length of survival. Descriptive and exploratory statistical analyses were performed. ResultsHospital admission, multiple (≥4x) ED visits, and respiratory cancer were independent risk factors for receiving only BPC (OR: 3.10, CI: 1.90–5.04; OR: 2.97, CI: 1.50–5.84; OR: 1.82, CI: 1.03–3.22, respectively), or HC (OR: 2.15, CI: 1.26–3.67; OR: 4.94, CI: 2.51–9.71; OR: 2.07, CI: 1.10–3.91). Visiting the ED only once was found to be a negative predictive factor for BPC (OR: 0.28, CI: 0.18–0.45) and HC (OR: 0.18, 0.10–0.31) among patients with cancer visiting the ED. ConclusionsOur study is the first from this European region to provide information regarding the characteristics of patients with cancer receiving BPC and HC who visited the ED, as well as to identify possible predictive factors of receiving BPC and HC. Our study may have relevant implications for health care planning strategies in practice.

Economics of Emergency Department Visits by Patients With Inflammatory Bowel Disease: A Real-World Analysis.

Inflammatory bowel disease (IBD) is associated with significant psychosocial, economic, and physical burden on patients. IBD care in the United States results in significant healthcare expenditure with recurring emergency department (ED) care and hospital admissions. Despite advances in therapy and improved access to specialty care, there is still room for improvement in cost-efficient care. Specialty medical homes and interdisciplinary care models have emerged as ways to improve medical care, patient outcomes, and quality of life, as well as improve the impact of healthcare costs. There is limited real-world data on cost in the United States, with many articles citing cost estimates from models. We analyzed real-world data from our tertiary care center with a focus on recurrent ED visits by IBD patients. Descriptive statistics were used for a cost analysis of multiple ED visits by IBD patients. Patients with ≥4 visits to the ED in a 6-month period were described as SuperUsers and were included in a separate analysis. The cost of hospitalization was also included. Total cost associated with all ED visits from SuperUsers were $72999.57 with an average of $6636.32 per patient. When the patients were admitted, the total cost of ED visits and hospitalizations was $721461.52, with an average of $65587.41 per patient. ED utilization by IBD patients with or without hospitalization is expensive and is typically driven by a cohort of SuperUsers. More work needs to be done to improve cost-effectiveness in IBD care, including reducing the frequency of ED visits.

Peer Recovery Specialists and Referrals to Treatment: Clinical Correlates Among Patients of an Opioid Overdose Recovery Program in New Jersey.

Peer recovery programs increase recovery support and treatment engagement among individuals with opioid use disorder. Peer recovery specialists (PRS) are critical in the cascade of care of treating addiction and related conditions. Work remains to help identify the benefits of PRS, particularly time spent with a PRS as a clinical indicator associated with referral to substance use treatment services. Gaps in the literature do not consider the nested hierarchical intercorrelations of opioid recovery data within multiple emergency departments. The current study examined demographic and clinical correlates with referral to substance use treatment services including prior engagement within an opioid overdose recovery program, mental health diagnosis, the number of naloxone administrations, prior overdoses, and hospital-level variability of PRS time associated with treatment referrals. This study used data collected by providers among patients who engaged in an opioid overdose recovery program. Data were collected between January 2016 and September 2020. Generalized linear mixed effect multilevel regression analyses tested the associations on clinical referral to substance use services. A total of 5655 patients participated in the study (male: 68.91%; age: mean = 37.75 ± 12.43; White non-Hispanic: 62.48%). Significant individual-level associations were identified between demographic and clinical variables and referral to substance use treatment services. At the hospital level, recovery specialist time spent with the patient also showed a positive and significant association with referral to substance use treatment services. The cross-level interaction effect displayed that any period of time spent with PRS played an important role for those patients with a greater number of prior overdoses on referral to treatment. Results provide important information on the role of PRS in the cascade of care, as well as the time spent with those in this role for both individuals with varying number of prior overdoses.

Multiple Chronic Condition Emergency Department Visits Among U.S. Adults: Disparities at the Intersection of Intellectual and Developmental Disabilities Status and Race or Ethnicity.

The study aims to examine the risk of multiple chronic condition (MCC)-related emergency department (ED) visits, MCC-related hospitalization following the ED visit, and mortality after MCC-related ED visits among adults with intellectual and developmental disabilities (IDD), adults compared with nondisabled adults by race and ethnicity, using the 2020 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. We identified IDD adults using ICD-10-CM codes, extracting 296,394 nondisabled adults and 99,538 IDD adults, of which 67,771 are white, 19,164 are black, 10,667 are Latinx, and 1936 are other race or multiple race. The control group of nondisabled adults was age-matched and sex-matched in a 1:3 case-control ratio. We conducted multilevel Poisson regression models for the binary-dependent variables and adjusted for covariates, including sociodemographic and hospital characteristics. The results show that across all racial/ethnic groups, individuals with IDD have significantly higher rates of MCC-related ED visits, hospitalizations, and deaths compared with nondisabled. Moreover, the disparities are more pronounced for individuals from racial/ethnic minority groups. Black and Latinx individuals with IDD have significantly higher rates of MCC-related ED visits and poor outcomes than their white counterparts with and without IDD. The findings from this study highlight significant racial and ethnic disparities in the risk of MCC-related ED visits, hospitalization following the ED visit, and mortality through the ED among IDD adults. This underscores the importance of adopting a multifaceted approach that addresses the social determinants of health, enhances access to health care, improves quality of care, and enhances care coordination.

The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness.

To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas. Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide. Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life. The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months. Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points. MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.

Emergency Department Volumes After State-Wide Lockdown Orders Across the United States During the COVID-19 Pandemic: COVID-19 lockdown and emergency volume.

The objective of this study was to describe changes in emergency department volumes after statewide lockdown in a network of hospitals across the United States during the COVID-19 global pandemic. A retrospective study was performed utilizing data on daily volumes across multiple emergency departments from a centralized data warehouse from a private for-profit hospital system during the COVID-19 pandemic. The mean daily volumes of 148 emergency departments were evaluated across 16 states in relation to each state's governmental statewide lockdown orders. Comparisons of the same period in the prior year were evaluated for percent changes in volumes. We also compared pre-lockdown to post-lockdown volumes. A separate analysis was made for the pediatric ED volumes. The 2020 post-lockdown volumes compared to the same 2019 dates revealed a mean percent change of -43.09%. The overall post-lockdown volumes compared to the pre-lockdown volumes had a mean percent change of -45.00%. The pediatric data revealed a greater mean percentage change in volumes of -71.52% (post-lockdown compared to 2019) and -69.03% (post-lockdown compared to pre-lockdown). This study found an overall decrease in volumes among 148 emergency departments across 16 states when compared to the comparable period pre-global pandemic.

An Innovation Approach for Optimal Resource Allocation in Emergency Management

In metropolitan regions, emergency events with different severity levels usually require multiple resources that have appropriate functionalities, money expenditure, moving velocities, etc. These resources could distribute over an extensive area with different ownerships. Solving the resource allocation problem for such an event involves complicated collaboration of multiple emergency departments under strict time constraints. Traditional resource allocation approaches usually have difficulties to efficiently find out the best resource assignment within the time limits by considering the large number of possibilities, which result in a considerable increase in fatalities. In this paper, a multiagent-based decentralised resource allocation approach using the domain transportation theory is proposed to handle a multi-task emergency event. The proposed approach is designed to effectively select appropriate resources without the global information and to concurrently generate the resource deployment plans for multiple tasks by considering the severity level of an emergency event. In the experiments, the proposed approach is tested along with other related approaches, and the experimental results indicate that the proposed approach can efficiently generate the optimal solution in terms of resource allocation time and money expenditure.

Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report

BackgroundDiagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. Case ReportWe present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an “intrauterine gestational sac” along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. Why Should an Emergency Physician Be Aware of This?This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to “clinically correlate.”

An educational intervention in the emergency department seeking to improve COVID-19 vaccination rates among unvaccinated patients aged 20-64.

The COVID-19 vaccination rate in the US has plateaued, especially among minorities and young populations. Previous efforts within the Emergency Department (ED) setting to address this disparity have shown positive results. The ED can play a crucial role in engaging vaccine-hesitant individuals, particularly those with limited access to healthcare. By providing education, addressing concerns, and using positive framing, vaccination rates can be improved in the ED. This quality improvement project aimed to increase vaccination rates through one-on-one educational interventions and open discussions with patients. Between November 2021 and June 2022, unvaccinated adult patients aged 20 to 64 visiting a local ED in Kalamazoo, MI were approached for a discussion on COVID vaccines. A research team, trained in motivational interviewing techniques, provided an educational intervention, offering evidence-based information and resources to unvaccinated participants. A total of 37 participants were enrolled, and their demographics were recorded. The participants expressed various concerns about the vaccine, including potential side effects, speed of testing and production, perceived ineffectiveness, mistrust, and low personal risk. At the four-week follow-up, three participants (8%) had received their first dose of the COVID-19 vaccine. The study fell short of its desired sample size and the intervention failed to raise vaccination rates among ED patients. Factors like low perceived risk, vaccine hesitancy, and limited resources may have influenced these outcomes. Future research should focus on staffing, operational hours, repeated educational interventions, and targeted approaches for different populations. Improving participant recruitment through institutional engagement and involvement of multiple EDs should be explored. Addressing these factors can help inform effective interventions to increase COVID-19 vaccination rates in the ED.

FRI371 Serum Androstenedione As An Additive Biomarker In Ectopic Cushing’s Syndrome Evaluation

Abstract Disclosure: S. Zhang: None. J.C. Lo: None. M.G. Jaffe: None. H. Arzumanyan: None. Background: Ectopic Cushing’s syndrome (ECS) results from glucocorticoid excess secondary to ectopic ACTH or CRH producing tumors. Although ECS identification can be challenging when presentation lacks classic Cushing’s features, ectopic ACTH secretion can result in a key constellation of findings that facilitate early clinical recognition. We describe a case of ECS from an ACTH-producing carcinoid tumor of the lung presenting with resistant hypertension, severe hypokalemia, and muscle weakness. In addition to significant hypercortisolism, laboratory findings were notable for high androstenedione levels without concomitant increase in DHEAS and testosterone levels. Case: A 59-year-old female athlete with history of well-controlled hypertension developed difficult to control hypertension, requiring escalation to triple antihypertensive therapy within 3 months. During this time, she had multiple emergency department visits for progressive muscle weakness, hypertension, and persistent hypokalemia despite potassium supplementation. She was hospitalized for further evaluation. Physical examination was notable for bruising, muscle wasting, thin extremities, facial fullness, and disproportionate abdominal adiposity. Workup for Cushing’s syndrome demonstrated ACTH-dependent hypercortisolism and markedly elevated androstenedione 398 ng/dL (normal 20-75 ng/dL) despite normal DHEAS 48 mcg/dL (normal &amp;lt;430 mcg/dL) and total testosterone 11 ng/dL (normal &amp;lt;45 ng/dL) levels. A chest CT identified a 3.8 cm right lower lobe lung mass and transbronchial biopsy confirmed atypical carcinoid tumor. She underwent a right middle and lower lobe bilobectomy with complete tumor resection. Cortisol, androstenedione, and potassium levels rapidly normalized postoperatively, and blood pressure returned to baseline, well-controlled on monotherapy. The patient only required 3 days of hydrocortisone therapy for transient steroid withdrawal symptoms. Conclusions: Our case illustrates a difficult to diagnose uncommon disease presenting with resistant hypertension, hypokalemia and marked androstenedione elevation despite normal DHEAS and testosterone levels. This steroidogenic profile has been reported in other ECS cases and attributed to differential effects of ectopic ACTH production on adrenal androgen biosynthesis (1). Although ECS is rare and the primary lesion can be difficult to identify, disproportionate elevation in androstenedione may prompt recognition of ECS and support early detection and management. Reference: (1) Barbetta L, Dall’Asta C, Re T, Colombo P, Travaglini P, Ambrosi B. Androgen secretion in ectopic ACTH syndrome and in Cushing’s disease: modifications before and after surgery. Horm Metab Res Horm Stoffwechselforschung Horm Metab. 2001;33(10):596-601 Presentation: Friday, June 16, 2023

SAT218 Refractory Hypocalcemia From Combined Autosomal Dominant Hypocalcemia Type 2 And Postsurgical Hypoparathyroidism

Abstract Disclosure: M. Sonmez Ince: None. F. Hannan: None. N. Esfandiari: None. M. Hussain: None. M.R. Haymart: None. R.V. Thakker: None. G.A. Clines: None. Background: Autosomal dominant hypocalcemia type 2 (ADH2), due to activating mutations in GNA11, is a rare disorder that causes hypocalcemia with low or inappropriately normal PTH. Postsurgical hypoparathyroidism (PSHP) is the most common etiology for hypoparathyroidism. The patient described was afflicted by both conditions and had persistent hypocalcemia despite aggressive management. Clinical Case: A 50-year-old female was found to have an enlarged thyroid on exam and subsequently diagnosed with papillary thyroid cancer (PTC). She underwent a total thyroidectomy without parathyroid autotransplantation since parathyroid glands were not identified during intraoperative pathologic survey. Surgical pathologic examination confirmed PTC with the identification of a single and small intrathyroidal parathyroid gland. Due to the patient’s low risk (T1N0M0), radioactive iodine ablation was not performed. Before thyroidectomy, serum corrected calcium was 6.4-8.5 mg/dL (8.6-10.3 mg/dL) and PTH was 9-21 pg/mL (10-65 pg/mL) during the previous 20 years. Following thyroidectomy, the patient had multiple emergency department visits due to hypocalcemia, hand cramping, and paresthesias. The patient was diagnosed with postsurgical hypoparathyroidism: corrected calcium 5.6-6.7 mg/dL, 24-hour urine calcium 112 mg (100-300 mg/24hour), magnesium 1.4-1.9 mg/dL (1.6-2.6 mg/dL), phosphorus 3-8.2 mg/dL (2.7-4.6 mg/dL). PTH remained &amp;lt;6 pg/mL. The patient was then referred to an academic endocrinology. TSH, AM cortisol, 25-vitamin D, iron, ceruloplasmin, copper, and 21-hydroxylase antibody concentrations were normal. Genetic testing revealed a pathogenic GNA11 variant (c.178C&amp;gt;T, p.(Arg60Cys)); no mutations were identified with CASR or AP2S1. Despite aggressive management with total daily oral calcitriol up to 12 mcg daily, calcium 8 grams, and chlorthalidone, the patient required calcium infusions thrice weekly. Despite the addition of teriparatide 20 mcg BID, the patient remained dependent on calcium infusions, with improvement after the addition of IV calcitriol. Recently, continuous teriparatide delivery was started using an Omnipod insulin pump that has significantly reduced the patient’s dependence on calcium infusions with serum calcium that are now 8-9 mg/dL. Conclusion: ADH2, due to gain-of-function mutations of GNA11, that encodes the Gα11 protein, causes life-long hypocalcemia that is often asymptomatic and undiagnosed. We report here the first documented case of combined ADH2 and PSHP. This case highlights that patients with ADH2 likely have hypoplastic parathyroid glands and that caution is required with procedures that may disrupt parathyroid gland function. Furthermore, the refractory nature of this patient’s hypocalcemia may suggest that GNA11 mutations in the kidney and skeleton reduce the effectiveness of standard hypocalcemia treatments. Presentation: Saturday, June 17, 2023

Exploring the impact of missingness on racial disparities in predictive performance of a machine learning model for emergency department triage.

To investigate how missing data in the patient problem list may impact racial disparities in the predictive performance of a machine learning (ML) model for emergency department (ED) triage. Racial disparities may exist in the missingness of EHR data (eg, systematic differences in access, testing, and/or treatment) that can impact model predictions across racialized patient groups. We use an ML model that predicts patients' risk for adverse events to produce triage-level recommendations, patterned after a clinical decision support tool deployed at multiple EDs. We compared the model's predictive performance on sets of observed (problem list data at the point of triage) versus manipulated (updated to the more complete problem list at the end of the encounter) test data. These differences were compared between Black and non-Hispanic White patient groups using multiple performance measures relevant to health equity. There were modest, but significant, changes in predictive performance comparing the observed to manipulated models across both Black and non-Hispanic White patient groups; c-statistic improvement ranged between 0.027 and 0.058. The manipulation produced no between-group differences in c-statistic by race. However, there were small between-group differences in other performance measures, with greater change for non-Hispanic White patients. Problem list missingness impacted model performance for both patient groups, with marginal differences detected by race. Further exploration is needed to examine how missingness may contribute to racial disparities in clinical model predictions across settings. The novel manipulation method demonstrated may aid future research.

Epidemiology of adult injuries: A multi-center study in greater Beirut

IntroductionInjury accounts for nearly 4 million deaths and 63 million disabilities annually. The injury burden is disproportionally large in low- and middle-income countries (LMICs), including Lebanon. This study aims to examine the characteristics and patterns of adult injuries presenting at multiple emergency departments (ED) in Lebanon and further identifies factors associated with hospital admission. Materials and methodsA retrospective cross-sectional study was conducted on adult patients (aged≥16) who presented with an injury to one of the five participating EDs from June 2017 to May 2018. Pan-Asia Trauma Outcomes Study (PATOS) variables were adopted for data collection. A descriptive analysis was performed, followed by bivariate and multivariate logistic regression to identify injury risk factors for hospital admission. ResultsA total of 3,716 patients’ records were included. Most injuries were sustained by males (62.7%), patients aged between 16 and 35 years (16–25: 28%; 26–35: 22.7%), and above 65 years (15.6%). Most injuries were unintentional (94.9%). Falls were highly prevalent across all age groups (38.8%), more proclaimed among the older adults’ population (56–65:52.8%; ≥66:73.7%), followed by struck-by object (23.6%) and transport injuries (10.1%). Upper and lower extremity injuries were common across all ages. Most patients (80.9%) were treated and discharged at the ED, 11.4% were admitted to the hospital, 4.3% were transferred to other trauma care facilities, and 2 patients died in the ED. Factors positively associated with hospital admission included: older age (≥ 56 years); private insurance; spine and lower extremity injuries; fractures, cuts/open wounds, concussion, and organ injuries (p-value≤0.05; OR>1). ConclusionInjury is a neglected public health problem in many LMICs, including Lebanon. While youth and the elderly are most affected, injuries occur across all age groups. This study lays the foundation for establishing a population-based injury surveillance system, crucial for designing tailored injury prevention programs to reduce injury-related deaths and disabilities.