Multiple Emergency Department Research Articles

Outcomes and Cost of Patients With Terminal Cancer Admitted to Acute Care in the Final 2 Weeks of Life: A Retrospective Chart Review.

Patients with terminal conditions are often admitted to the emergency department (ED) for acute medical services, but studies have suggested that multiple ED admissions may negatively impact end-of-life (EOL) care. Research have shown that incorporating palliative care (PC) is integral to optimal EOL care, but it is an aspect of medical practice that is often neglected. The current study sought to provide an overview of health outcomes and hospital costs of patients with cancer admitted to The Ottawa Hospital and/or received acute medical services during their final 2 weeks of life. Cost comparisons and estimates were made between hospital and hospice expenditures. We conducted a retrospective chart review of palliative patients who died at The Ottawa Hospital in 2012. A total of 130 patients who visited the ED within 2 weeks of death were included in the analyses. In this cohort of patients, 71% of admitted patients did not have advanced care directives and 85% experienced a metastasis, but only 18% had a PC medical doctor. Patients were hospitalized, on average, for 7 days and hospitalization costs exceeded the estimated hospice cost by approximately 2.5 times (Can$1 041 170.00 at Can$8009.00/patient vs Can$401 570.00 at Can$3089.00/patient, respectively). Our study highlighted the importance of PC integration in high-risk patients, such as those in oncology. Patients in our sample had minimal PC involvement, low advanced care directives, and accrued high costs. Based on our analyses, we concluded that these patients would have likely benefited more from hospice care rather than hospitalization.

30-Day Emergency Department Visits After Primary Lumbar Fusion: Incidence, Causes, Risk Factors, and Costs.

Our objective was to describe the incidence, causes, risk factors, and costs associated with 30-day emergency department (ED) visits after primary lumbar fusion. A national insurance database was retrospectively analyzed to study patients with primary lumbar fusions performed for degenerative pathology of the spine between 2007 and Q3-2015. Risk factors for ED visits, and ED to hospital transfer were studied using multiple-variable logistic regression analysis. Our cohort included 37,559 patients with a mean age of 66.0±10.0 years. A total of 4806 (12.8%) patients had 10,281 ED visits within 30 days after surgery. Of these, 945 (19.9%) had multiple (≥3) visits, and 1466 (30.5%) were admitted to the hospital for management. Common causes for presentation in the ED were cardiorespiratory complaints (49.4%, n=2377), and back and/or leg pain (47.7%, n=2294). Risk factors for all ED visits, multiple ED visits, and hospital admission from the ED have been identified. The overall ED cost burden was nearly two-thirds as much as hospital readmissions within 30 days ($6,994,260 vs. $10,880,999). There is a sizable subset of patients that present to the ED for acute care but do not require hospitalization. Causes and risk factors for presentation in patients with multiple ED visits are somewhat different than patients requiring hospital readmission.

A Prospective, Multicenter Evaluation of Point-of-care Ultrasound for Small-bowel Obstruction in the Emergency Department.

The main objective of this study was to evaluate the accuracy of emergency physician-performed point-of-care ultrasound (POCUS) for the diagnosis of small-bowel obstruction (SBO) compared to computed tomography (CT). We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential SBO presenting to the emergency department (ED) between July 2014 and May 2017. Each POCUS was interpreted at the bedside by the performing emergency physician and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS, blinded expert interpretation, and specific POCUS parameters. A total of 217 subjects were included in the primary analysis with an overall SBO prevalence of 42.9%. For the diagnosis of SBO, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.88 (95% confidence interval [CI]= 0.80 to 0.94), 0.54 (95% CI= 0.45 to 0.63), 1.92 (95% CI= 1.56 to 2.35), and 0.22 (95% CI= 0.12 to 0.39), respectively. Expert review yielded a similar sensitivity (0.89 [95% CI= 0.81 to 0.95]) with a significantly higher specificity (0.82 [95% CI= 0.74 to 0.88]). The more sensitive sonographic parameters for both POC sonographers and expert reviewers were small-bowel dilation ≥ 25 mm (0.87 [95% CI= 0.79 to 0.93], 0.87 [95% CI= 0.79 to 0.93]) and abnormal peristalsis (0.82 [95% CI= 0.72 to 0.89], 0.85 [95% CI= 0.76 to 0.87]). The more specific parameters for both groups were transition point (0.82 [95% CI= 0.74 to 0.89], 0.98 [95% CI= 0.94 to 1.00]), intraperitoneal free fluid (0.82 [95% CI= 0.74 to 0.89], 0.93 [95% CI= 0.87 to 0.97]), and bowel wall edema (0.76 [95% CI= 0.67 to 0.83], 0.93 [95% CI= 0.87 to 0.97]). POCUS is moderately sensitive for SBO, although less specific, when performed by a diverse group of emergency physicians across multiple EDs. Interpretation of acquired POCUS images is significantly more accurate when performed by physicians with prior emergency ultrasound fellowship training and familiarity with the sonographic appearance of SBO.

Recurrent Emergency Department Users: Two Categories with Different Risk Profiles.

Recurrent emergency department (ED) visits are responsible for an increasing proportion of overcrowding. Therefore, our aim was to investigate the characteristics and prevalence of recurrent ED visitors as well as to determine risk factors associated with multiple ED visits. ED patients visiting the ED of a tertiary care hospital at least four times consecutively in 2015 were enrolled. Of 33,335 primary ED visits, 1921 ED visits (5.8%) were performed by 372 ED patients who presented in the ED at least four times within the one-year period. Two different categories of recurrent ED patients were identified: repeated ED users presenting always with the same symptoms and frequent ED visitors who were suffering from different symptoms on each ED visit. Repeated ED users had more ED visits (p < 0.001) and needed more hospital admissions (p < 0.010) compared to frequent ED users. Repeated ED users visited the ED more likely due to symptoms from chronic obstructive pulmonary diseases (p < 0.001) and mental disorders (p < 0.001). In contrast, frequent ED patients showed to be at risk for multiple ED visits when being disabled (p = 0.001), had an increased Charlson co-morbidity index (p = 0.004) or suffering from rheumatic diseases (p < 0.001). A small number of recurrent ED visitors determines a relevant number of ED visits with a relevance for and impact on patient centred care and emergency services. There are two categories of recurrent ED users with different risk factors for multiple ED visits: repeated and frequent. Therefore, multi-professional follow-up care models for recurrent ED patients are needed to improve patients’ needs, quality of life as well as emergency services.

Using pharmacy technicians and telepharmacy to obtain medication histories in the emergency department

To determine if telepharmacy can be used to collect medication histories on patients admitted in the emergency department (ED) in a large health system. As part of an effort to address safety concerns, resource limitations, and a decline in medication history completions, a program was developed to use telepharmacy to conduct medication histories on patients admitted in the ED. The medication history program covers 5 large facilities. It is staffed by 6 full-time pharmacy technicians 7 days a week and is overseen by a pharmacist. Medication histories are conducted with the use of mobile carts enhanced with videoconferencing equipment allowing technicians to operate from a remote central location. The program allows the technicians to observe multiple EDs at one time, interview patients through videoconferencing, and document completed medication histories in the electronic medical record (EMR). The technicians also transcribe preoperation (pre-op) medication lists for patients being admitted for surgeries. Medication history completion rates and barriers were assessed. In addition, potential medication errors, medication history accuracy rates for nursing and pharmacy technicians, and a cost analysis of preventable ADEs were explored. The program, on average, conducts medication histories on 56% to 79% of patients admitted through the ED during hours of operation. In fiscal year 2018, the technicians entered 24,980 medication histories and pre-op lists. A cross-sectional analysis of data collected from December 2016 to March 2017, including 124 patients, revealed 320 potential medication errors among a total of 382 high-risk medications. Based on the current performance and continued expansion of this novel strategy, use of telepharmacy to obtain medication histories in the ED has led to resource optimization for the remote delivery of a pharmacy service.

The Healthcare Burden of Emergency Department Utilization for Multiple Myeloma: A Five Years U.S. Nationwide Study

Abstract Introduction: Multiple myeloma is comparatively uncommon cancer, but among blood malignancies it is still the second most common cancer after non-Hodgkin lymphoma. Patients with complications of multiple myeloma (MM) frequently present to the emergency department. There is a lack of data about the health care burden and trends of utilization of emergency department services by MM patients. The objective of this study is to investigate the recent trends in resource utilization in the emergency departments for MM. Furthermore, we aimed to look for the demographic characteristics associated with the subsequent hospitalization of MM patients. We hypothesized that there has been an increase in the utilization of emergency department services for the management of MM patients in recent years. We further hypothesized that subsequent hospitalization rate may be decreasing with the availability of more efficacious and potentially less toxic drugs. Methods: For this study we obtained the data from United States National Emergency Department Sample (NEDS) years 2010-2014. For categorical variables, frequencies and proportions were generated and statistical significance was tested using a chi-squared test. Rate of myeloma associated emergency department visits were estimated by using US census population. Patients and hospital characteristics were entered in univariate analysis to predict in-patient admissions from the ED. Multivariable logistic regression was used to predict in-patient admissions for the variables that were found statistically significant in univariate analysis. All tests were two-sided with the statistical significance set at p &lt; 0.05. All analyses were conducted using STATA 14.2v and no missing data was imputed. Results: Between 2010 to 2014, approximately 443,214 patients visited emergency departments (ED) with the diagnosis of MM, that accounted for 0.06 % of all emergency department visits. There was an absolute increase of 22% in MM related visits from 80,466 in 2010 to 98,279 in 2014. While the rate of emergency department service utilization by myeloma patient increased significantly by 19% (p=0.04). Overall 73% of myeloma related visits resulted in hospitalization, but over the study period trend of hospitalization decreased. The percentage of patients treated and discharged to home increased from 23% to 29% between 2010 to 2014. Total charges associated with myeloma related visits increased significantly from $315 million to $626 million during 2010 to 2014, with an annual increase in the rate (19.26%: p&lt;0.001). In the multivariable regression analysis several characteristics of patients and hospitals were found to be positively associated with the higher odds of hospitalization following a myeloma related visit. Male gender (OR 1.09, p&lt;0.001), age category 18-64 years (OR 4.3, p=0.002), age of 65 and above (OR 4.7, p=0.001), Medicaid insurance (OR 1.38, p&lt;0.001), northeast location of hospital (OR 2.51, p&lt;0.001), metropolitan non-teaching hospitals (OR 1.18, p&lt;0.001), more number of co-morbidities (OR 1.51, p&lt;0.001) and profit ownership of hospital (OR 1.5, p&lt;0.01). Conclusion: Multiple myeloma related emergency department service utilization and total charges are increasing over the observed time limit. While the incidence of hospitalization from emergency department is decreasing overtime. These findings can be explained on the basis of few facts. MM patients are living longer with the availability of newer drugs but remain uncured. Most patients will face relapse after the initial disease control, at which point they may need to utilize ED services more frequently. As better oral or intravenous drugs are available through oncology out-patient offices, limited MM drug choices are available in the hospital, majority of MM patients are discharged sooner from the hospitals resulting in reduced hospital admission rates as well as shorter hospital stay. Disclosures No relevant conflicts of interest to declare.

Transcranial Doppler Screening Adherence Among Children with Sickle Cell Anemia Seen in the Emergency Department

Abstract Background: Annual transcranial doppler (TCD) screening is strongly recommended for patients with sickle cell anemia (SCA) between the ages of 2 to 16 years to identify children at highest risk for stroke. Implementation of this screening and treating identified patients with chronic transfusion has decreased the incidence of overt stroke. Nonetheless, adherence to TCD screening guidelines is poor and many children with SCA do not receive an annual TCD. The purpose of this study is to evaluate adherence to TCD screening among a cohort of patients with SCA seen in the emergency department (ED) for an acute problem. Previous work has demonstrated that SCD-related outpatient visits are important "missed opportunities" for TCD screening. We hypothesized that ED encounters also represent potential opportunities to identify patients in need of TCD screening who do not attend clinic regularly. Methods: We conducted a retrospective chart review of the medical records of all patients with sickle cell disease (SCD) seen in the ED at a large, urban pediatric institution between February 2016 and April 2017. Patients were identified using an ED clinical registry that includes all ED patient encounters. We excluded patients who do not need TCD screening (sickle cell disease genotypes other than SS and Sβ0 thalassemia, age &lt;2 or &gt;16 years, on chronic transfusions, history of hematopoietic stem cell transplant). We also excluded patients documented to previously have inadequate TCD bone windows and patients who did not receive their regular hematology care at the study institution. For eligible patients who had multiple ED encounters during the study period, data was extracted at the time of the first ED encounter during the study period. Eligible patients who had received a TCD in the last year (adherent to TCD screening) were compared to patients who had not received a TCD in the last year (nonadherent to TCD screening). Categorical data was analyzed with the chi-square test. Continuous data was analyzed using the two-sample t-test. P value of &lt;0.05 was considered statistically significant. Results: During the 64 week study period, 739 patients with SCD were seen in the ED. A total of 482 patients were excluded for the following reasons: non-SCA genotype (n=164), age (n=139), followed at outside institution (n=129), chronic transfusion (n=38), prior TCD window problem (n=10), history of transplant (n=2); leaving 257 patients with SCA aged 2-16 years for study. Among this study group, 63 patients (25%) had not received a needed TCD in the last year, including 19 patients (7%) who had never had a TCD. When excluding patients aged 2-2.99 years (n=33) in whom a first TCD may have been planned soon after the ED encounter, a similar proportion of patients still had not received a TCD in the last year (53/224, 24%) but a slightly smaller proportion had never had a TCD (9/224, 4%). Patient age and sex were not associated with TCD screening adherence (p&gt;0.7). Patients adherent to TCD screening were more likely to be taking hydroxyurea (67% vs. 29%, p&lt;0.0001). A recent hematology clinic visit was significantly associated with TCD screening adherence. All patients adherent to TCD screening had a clinic visit in the last year compared to 75% of nonadherent patients, p&lt;0.0001. The mean interval time since the last hematology clinic appointment from the ED encounter was greater for TCD nonadherent patients, 70 vs. 270 days p&lt;0.0001 (Figure). Conclusion: Patients with SCA who present to the ED and are nonadherent to TCD screening guidelines are less likely to have had a recent hematology clinic visit. Therefore, the ED may be an important location for identifying patients lost to regular clinic follow-up in need of a TCD. An intervention that specifically targets this patient population will likely improve TCD screening rates and stroke prevention. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Nausea in the peri-traumatic period is associated with prospective risk for PTSD symptom development.

While nausea often develops following exposure to trauma, little is known regarding the relationship between peri-traumatic nausea and prospective risk for developing posttraumatic stress disorder (PTSD). We examined the association between peri-traumatic nausea and PTSD symptom development in three independent cohorts. Participants were recruited from (1) the Emergency Departments (ED) at Grady Memorial Hospital (GMH) in Atlanta, GA, (2) from multiple other ED sites in the TRYUMPH Research Network, and (3) from the ED during evaluation for suspected acute coronary syndrome in the REACH cohort. Administration of IV ondansetron, the most predominant antiemetic used at GMH, was used as a surrogate marker for nausea in the initial GMH cohort; nausea was then directly assessed in the internal validation at GMH, and within the replication TRYUMPH Research Network and REACH cohorts. In the GMH cohort (N = 363), ondansetron administration was associated with increased 1- and 3-month posttrauma PTSD symptoms in adjusted models (all p's < 0.05). In the GMH internal validation, nausea significantly predicted 1 month (p = 0.009; n = 68) and 3 month (p = 0.029; n = 54) PTSD symptoms. In the TRYUMPH cohort (N = 1846), patient reported nausea in the ED was significantly associated with increased PTSD symptoms (p = 0.009) in adjusted models. In the REACH cohort (N = 758), peri-traumatic nausea was associated with PTSD symptom severity at the 1-month follow-up in adjusted models (p's ≤ 0.008). The current prospective data from three independent cohorts suggest that peri-traumatic nausea is a prospective predictor of PTSD symptom development. Further studies are needed to determine the mechanistic role of nausea as an intermediate phenotype of PTSD risk.

A Machine Learning Approach to Identifying Future Suicide Risk

Background It is nearly impossible to predict when someone will die from suicide, but with early intervention many deaths are preventable. Clinical trials using machine learning algorithms have been able to use patient language to compute the likelihood that someone is suicidal at a particular point in time. Here we determine if the language characteristics associated with suicide risk are persistent 30 days after discharge. Methods Multiple hospital base emergency departments and outpatient clinics were used to enroll subjects (n=253) into one of two groups: suicidal or control. Their responses to standardized instruments and interviews designed to harvest thought markers were recorded and analyzed with machine learning algorithms. Subjects were re-interviewed approximately 30 days later, and the language in their interviews was analyzed to determine the presence of suicidal ideation. Outcomes The results show that the language characteristics used to classify suicidality at the initial encounter are still present in the participants’ speech 30 days later (AUC = 0·89 (95% CI: 0·85-0·95) with p < 0·0001) and that this also holds in the inverse case; classifiers trained on second interviews could identify the cohort that produced the first interviews (AUC = 0·85 (95% CI: 0·81–0·90) with p < 0·0001). Interpretation This approach explores the stability of suicidal interviews 30 days after it is recorded. It does so with computational innovations and well established computational linguistic methods. The results show that the thoughts exhibited by a patient’s language are still valid for machine learning 30-days after first disclosed, but the initial correlation with the standard measures is not. This can be useful when seeking decision support for follow-up care. Funding Statement: Cincinnati Children’s Hospital Medical Center, Innovation Fund. Declaration of Interests: The authors have no competing interests to declare. Ethics Approval Statement: A prospective clinical trial was conducted between October 2013 and March 2015 (Institutional Review Board (#2013-3770) approved).

Acquired Angioedema as Unusual Cause of Recurrent Abdominal Pain

Acquired angioedema is a rare acquired deficiency of C1 inhibitor characterized by subcutaneous edema and/or submucosal edema of the respiratory or gastrointestinal tract. A 52-year old female with a history of chronic urticaria and recently treated Helicobacter pylori infection was admitted for recurrent epigastric abdominal pain with no new or worsening rash. Her medications included cetirizine, ranitidine, and montelukast. Laboratory work up showed normal lipase, transaminases, but mildly elevated ESR 24 mm/Hr and CRP 1.5 mg/dL. Contrast-enhanced CT abdomen showed duodenal and proximal jejunal wall thickening and mesenteric lymphadenopathy. Push enteroscopy with biopsies revealed normal duodenal and jejunal mucosa. She had multiple emergency department visits for abdominal cramping with facial swelling but without any rash, or shortness of breath. Immunological workup showed normal lymphocyte count, ANA titer 1:160, normal dsDNA, anti-Smith antibodies, normal serum immunoelectrophoresis, but low C1q complement (<5 U/mL), low C4 complement (<2 mg/dL), normal C3 complement, low C1 inhibitor (12 mg/dL) and low C1 inhibitor activity (4%); all consistent with acquired angioedema. She initially received intravenous methylprednisone and diphenhydramine without improvement, followed by fresh frozen plasma and subcutaneous icatibant 30 mg with a resolution of symptoms. Non-allergic angioedema is a rare disorder and includes medication induced and C1 inhibitor deficiency. Although mostly hereditary, C1 inhibitor deficiency can be acquired in association with lymphoproliferative disorders, infections, and autoimmune diseases. Acquired angioedema can present as chronic recurrent abdominal pain or mimic an acute surgical abdomen, even in absence of subcutaneous edema. Diagnosis is made by medical history and the level and activity of C4, C1q, and C1 inhibitor during an acute angioedema attack. Treatment options include C1 inhibitor concentrate, fresh-frozen plasma, and icatibant, which is a selective bradykinin receptor antagonist. Long-term prophylaxis is with antifibrinolytics and attenuated androgens. Our case highlights less common gastrointestinal presentation of acquired angioedema and the effectiveness of fresh frozen plasma and icatibant in its treatment. We also reiterate that early diagnosis of acquired angioedema is key for treatment of potentially life-threatening attacks and to initiate prophylaxis for recurrent attacks.2503_A Figure 1. Contrast enhanced CT abdomen showing small bowel wall (jejunal) thickening2503_B Figure 2. Push enteroscopy showing normal small bowel mucosa after resolution of acute angioedema attack

Cognition and Incarceration: Cognitive Impairment and Its Associated Outcomes in Older Adults in Jail

To determine prevalence of, and outcomes associated with, a positive screen for cognitive impairment in older adults in jail. Combined data from cross-sectional (n=185 participants) and longitudinal (n=125 participants) studies. Urban county jail. Individuals in jail aged 55 and older (N = 310; mean age 59, range 55-80). Inclusion of individuals aged 55 and older is justified because the criminal justice system defines "geriatric prisoners" as those aged 55 and older. Baseline and follow-up assessments of health, psychosocial factors, and cognitive status (using the Montreal Cognitive Assessment (MoCA)); 6-month acute care use and repeat arrest assessed in those followed longitudinally. Participants were of low socioeconomic status (85% annual income < $15,000) and predominantly nonwhite (75%). Many (70%) scored less than 25 on the MoCA; those with a low MoCA score were more likely to be nonwhite (81% vs 62%, p<.001) and report fair or poor health (54% vs 41%, p=.04). Over 6 months, a MoCA score of less than 25 was associated with multiple emergency department visits (32% vs 13%, p=.02), hospitalization (35% vs 16%, p=.03), and repeat arrests (45% vs 21%, p=.01). Cognitive impairment is prevalent in older adults in jail and is associated with adverse health and criminal justice outcomes. A geriatric approach to jail-based and transitional health care should be developed to assess and address cognitive impairment. Additional research is needed to better assess cognitive impairment and its consequences in this population. J Am Geriatr Soc 66:2065-2071, 2018.

Frequency and predictors of health services use by Native Hawaiians and Pacific Islanders: evidence from the U.S. National Health Interview Survey

BackgroundNative Hawaiians and Pacific Islanders (NHPIs) are one of the fasting growing racial groups in the United States (US). NHPIs have a significantly higher disease burden than the US population as a whole, yet they remain underrepresented in research. The purpose of this study is to examine factors associated with health care utilization among NHPIs.MethodsDrawing from the 2014 NHPI-National Health Interview Survey, we used stereotype logistic regressions to examine utilization of emergency department (ED) and outpatient services among 2172 individuals aged 18 and older.ResultsNHPIs with chronic diseases were twice as likely to be multiple ED users and nearly four times as likely to be frequent-users of outpatient services. Social support played a protective role in preventing multiple use of ED. Having a usual source of care made it more than eight times as likely to be a frequent-user of outpatient services. Use of eHealth information increased the odds of using ED and outpatient services. Ability to afford health care increased the odds of using outpatient services. There was no association between health insurance coverage and use of ED and outpatient services among NHPIs.ConclusionsThis research provides the first available national estimates of health services use by NHPIs. Efforts to improve appropriate use of health services should consider leveraging the protective factors of social support to reduce the odds of frequent ED use, and having a usual source of care to increase use of outpatient services.

Anxiety Associated With Increased Risk for Emergency Department Recidivism in Patients With Low-Risk Chest Pain

Anxiety contributes to the chest pain symptom complex in 30% to 40% of patients with low-risk chest pain seen in the emergency department (ED). The validated Hospital Anxiety Depression Scale-Anxiety subscale (HADS-A) has been used as an anxiety screening tool in this population. The objective was to determine the prevalence of abnormal HADS-A scores in a cohort of low-risk chest pain patients and test the association of HADS-A score with subsequent healthcare utilization and symptom recurrence. In a single-center, prospective, observational cohort study of adult ED subjects with low-risk chest pain, the HADS-A was used to stratify participants into 2 groups: low anxiety (score <8) and high anxiety (score ≥8). At 45-day follow-up, chest pain recurrence was assessed by patient report, whereas ED utilization was assessed through chart review. Of the 167 subjects enrolled, 78 (47%) were stratified to high anxiety. The relative risk for high anxiety being associated with at least one 30-day ED return visit was 2.6 (95% confidence interval 1.4 to 4.7) and this relative risk increased to 9.1 (95% confidence interval 2.18to38.6) for 2 or more ED return visits. Occasional chest pain recurrence was reported by more subjects in the high anxiety group, 68% vs 47% (p = 0.029). In conclusion, 47% of low-risk chest pain cohort had abnormal levels of anxiety. These patients were more likely to have occasional recurrence of their chest pain and had an increased risk multiple ED return visits.

Predictors of asthma relapse in patients who attended an emergency department.

Patients with asthma exacerbations and frequent relapses that require admission to the emergency department (ED) often have more severe disease, worse quality of life, and higher use of health care resources. The aim of this study was to identify potential predictors of relapse after patients are treated in an ED for an asthma exacerbation. A retrospective, noninterventional cohort study was conducted in adult patients who attended the ED of a tertiary hospital in 2014 for an asthma exacerbation. We analyzed the subpopulation who experienced at least one relapse (returned to the ED < 15 days after the previous event). Fifty-two of 831 patients experienced 66 relapses after going to the ED (mean ± standard deviation [SD] age, 58.5 ± 23.4 years). The average ± SD probability of a relapse was 6 ± 0.8%. The frequency of episodes was higher in May and November. Twenty-four patients had ≥260 blood eosinophils/μL, including 17 who had ≥400 eosinophils/μL. Only 15% of the patients were referred to an asthma specialist at discharge. Factors related to a higher probability of relapse were the following: having multiple visits to the ED in 1 year, uncontrolled asthma, wheezing in the pulmonary auscultation, peripheral eosinophilia with ≥400 eosinophils/ μL, and being discharged in the first visit to the ED (p < 0.01 for all). In this population, patients who had multiple ED visits in 1 year, those with uncontrolled asthma, wheezing, ≥400 blood eosinophils/μL, or who had been discharged at the first ED visit are at higher risk of relapse.

Effectiveness of a Rural Emergency Department (ED)-Based Pain Contract on ED Visits Among ED Frequent Users

Caring for patients with chronic pain in emergency departments (EDs) can be particularly challenging, for both patients and physicians. This study sought to determine, in a rural setting, the effect of an ED-based pain contract on the rate of ED visits among patients with frequent visits for pain not related to cancer. This is a multi-ED, retrospective, before-and-after chart review assessing the effect of a rural ED-based pain contract on the frequency of ED visits. The study setting consisted of four rural EDs representing over 85,000 annual visits. Medical records of patients eligible for a standardized pain contract during a 10-year period (December 2005-December 2015) were reviewed. Only visits involving complaints of pain were included. The number of visits during the year prior to contract initiation was compared with the number of visits during the year after enrollment, using a paired t-test. We enrolled 314 patients, 185 (59%) of whom were female. The study group's median age was 48years. The mean number of ED visits was 12.4 visits (95% confidence interval [CI] 11.5-13.3) 1year prior to the pain contract and 6.5 (95% CI 5.6-7.3) 1year afterward (p<0.0001). The mean number of ED visits decreased by 6.0 (95% CI 5.0-7.2). A pain contract protocol was associated with a significant reduction in the number of ED visits to multiple rural EDs.

Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia

Patients with critical limb ischemia (CLI) utilize hospital resources at high rates. One major driver for resource utilization is emergency department (ED) visits. Our goal was to assess perioperative ED visits after lower extremity bypass (LEB) for CLI. All patients undergoing LEB for CLI from 2008 to 2017 at our institution were analyzed. ED visits and details of the visit within 30 and 90days of discharge from index admission were recorded. Multivariable analysis was performed to identify risk factors for any ED presentation and ED presentation without hospital admission. There were 317 patients identified who underwent infrainguinal LEB for CLI. Average age was 66 years, and 60.6% of patients were male. Within 30 and 90days, 24.3% and 36.3% presented to the ED overall, and 16.7% and 26.5% of all postoperative patients had an ED presentation without hospital admission, respectively. Most common reasons for any ED visits and for ED visits without admission within 30days were wound complications (22.1% and 20.8%), cardiac complications (16.9% and 17%), and ipsilateral leg pain (10.4% and 11.3%), respectively. Cryopreserved vein bypass (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.02-8.84, P=0.046) and index length of stay (LOS) (OR 1.09, 95% CI 1.04-1.15, P<0.001) predicted any 30-day ED visit. Active leg infection at the time of bypass (OR 2.35, 95% CI 1.21-4.58, P=0.012) and index LOS (OR 1.05, 95% CI 1.004-1.09, P=0.033) predicted 30-day ED presentation without hospital admission. Most common reasons for any ED visit and for ED visits without admission within 90days were surgical wound complications (15.8% and 14.3%), cardiac complications (14.9% and 14.3%), and nonsurgical wounds (9.6% and 9.5%), respectively. Chronic renal insufficiency (CRI) (OR 2.73, 95% CI 1.52-4.93, P=0.001) and index LOS(OR 1.07, 95% CI 1.01-1.12, P=0.017) predicted any 90-day ED visit. CRI (OR3.34, 95% CI 1.81-6.17, P=0.001) predicted 90-day ED presentation without hospital admission. For multiple ED visits within 90days, there were 5 patients each with 5 ED visits, 12 each with 4 ED visits, 26 each with 3 ED visits, and 47 each with 2 ED visits. There is a high rate of ED utilization in CLI patients after LEB. Targeting these patients with closer follow-up and improved outpatient ambulatory access could assist in decreasing the frequency of postoperative ED visits. Particular areas of targeted improvement are those patients who presented to the ED and were not admitted.

Associated factors and costs of avoidable visits to the emergency department among cancer patients: 1-year experience in a tertiary care hospital in South Korea.

Patients receiving palliative care make avoidable emergency department visits (AvED), which may increase economic and social costs. However, the proportion of AvED among all patients, including cancer patients after curation, and the resulting costs are unknown in Asia. This study aimed to investigate the proportion, characteristics, and costs regarding factors associated with AvED among cancer patients. This retrospective cohort study analyzed the medical records of patients who visited the emergency department (ED) at a tertiary care hospital in Korea in 2016. Data regarding patients' demographic, cancer-related, and clinical characteristics were collected. ED visits by a total of 4346 patients were included in the analysis, of which 2420 visits (55.7%) were avoidable. In the multivariate logistic model, the following main factors were associated with AvED: stay in ED (odds ratio [OR] 0.998, 95% confidence interval [CI] 0.997-0.999, P < 0.001), distance to the home from the ED (OR 0.998, 95% CI 0.997-0.999, P < 0.001), multiple ED visits in 1year (OR 1.204, 95% CI 1.156-1.255, P < 0.001), primary progression (vs. after curation) (OR 0.748, 95% CI 0.627-0.892, P = 0.001), and chief complaint being a gastrointestinal symptom (vs. pain) (OR 1.871, 95% CI 1.188-2.946, P = 0.007). The average cost per visit in the AvED group was $369.80, and the annual total cost for all AvEDs was $894,877. Our study showed that 55.7% of all ED visits by cancer patients visiting the ED of a tertiary care hospital were avoidable, and several factors were associated with AvED.

P100: Exploring First Nations members emergency department experiences and concerns through participatory research methods

Introduction: Emergency Departments (EDs) are frequently the first point of entry to access health services for First Nation (FN) members. In Alberta, FN members visit EDs at almost double the rate of non-FN persons. Furthermore, preliminary evidence demonstrates differences in ED experience for FN members as compared to the general population. The Alberta First Nations Information Governance Centre, Maskwacis Health Services, Yellowhead Tribal Council, Treaty 8 First Nations of Alberta, and Alberta Health Services are working together to research FN members ED experiences and concerns. Methods: This is participatory research guided by a two-eyed seeing approach that acknowledges the equal value of both Western and Indigenous worldviews. FN and non-FN leaders researchers are full partners in the development of the research project. Six sharing circles will be held in February 2018 across Alberta, with Elders, FN patients, FN and non-FN clinicians and FN and non-FN administrators. Sharing circles are similar to focus groups, but emphasize everyone having a turn to speak and demonstrating respect among participants in accordance with FN protocols. Elders will select the questions for discussion based on topics that arose in initial team meetings. Sharing circle discussions will be audio recorded and transcribed. Analysts will include both Western and Indigenous worldview researchers, who will collaboratively interpret findings. Elders will review, discuss, contextualize and expand upon study findings. The research is also guided by FN principles of Ownership, Control, Access, and Possession of FN information. It is through these principles that First Nation research projects can truly be classified as FN lead and driven. Results: Based on initial team meeting discussions, results of sharing circles are expected to provide insights on issues such as: healing, patient-provider communication (verbal and non-verbal), shared decision making, respect for patient preferences, experiences leading to trust or distrust, understandings of wait times and triage, times when multiple (repeat) ED presentations occur, distances travelled for care, choosing specific EDs when seeking care, impacts of stereotypes about FN patients, and racism and reconciliation. Conclusion: Understanding FN ED experience and bringing FN perspectives to Western conceptions of the goals and provision of ED care are important steps toward reconciliation.

MP44: TEC4Home heart failure: using home telemonitoring to decrease ED readmissions and clinical flow

Introduction: Patients with Heart failure (HF) experience frequent decompensation necessitating multiple emergency department (ED) visits and hospitalizations. If patients are able to receive timely interventions and optimize self-management, recurrent ED visits may be reduced. In this feasibility study, we piloted the application of home telemonitoring to support the discharge of HF patients from hospital to home. We hypothesized that TEC4Home would decrease ED revisits and hospital admissions and improve patient health outcomes. Methods: Upon discharge from the ED or hospital, patients with HF received a blood pressure cuff, weight scale, pulse oximeter, and a touchscreen tablet. Participants submitted measurements and answered questions on the tablet about their HF symptoms daily for 60 days. Data were reviewed by a monitoring nurse. From November 2016 to July 2017, 69 participants were recruited from Vancouver General Hospital (VGH), St. Pauls Hospital (SPH) and Kelowna General Hospital (KGH). Participants completed pre-surveys at enrollement and post-surveys 30 days after monitoring finished. Administrative data related to ED visits and hospital admissions were reviewed. Interviews were conducted with the monitoring nurses to assess the impact of monitoring on patient health outcomes. Results: A preliminary analysis was conducted on a subsample of participants (n=22) enrolled across all 3 sites by March 31, 2017. At VGH and SPH (n=14), 25% fewer patients required an ED visit in the post-survey reporting compared to pre-survey. During the monitoring period, the monitoring nurse observed seven likely avoided ED admissions due to early intervention. In total, admissions were reduced by 20% and total hospital length of stay reduced by 69%. At KGH (n=8), 43% fewer patients required an ED visit in the post-survey reporting compared to the pre-survey. Hospital admissions were reduced by 20% and total hospital length of stay reduced by 50%. Overall, TEC4Home participants from all sites showed a significant improvement in health-related quality of life and in self-care behaviour pre- to 90 days post-monitoring. A full analysis of the 69 patients will be complete in February 2018. Conclusion: Preliminary findings indicate that home telemonitoring for HF patients can decrease ED revisits and improve patient experience. The length of stay data may also suggest the potential for early discharge of ED patients with home telemonitoring to avoid or reduce hospitalization. A stepped-wedge randomized controlled trial of TEC4Home in 22 BC communities will be conducted in 2018 to generate evidence and scale up the service in urban, regional and rural communities. This work is submitted on behalf of the TEC4Home Healthcare Innovation Community.

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

The role of joint working between primary and secondary care in supporting people with type 1 diabetes