Patient Care In Emergency Department Research Articles

P080: Clinical lead nurse practitioner Strathcona Community Hospital

Introduction: Prior to opening Strathcona Community Hospital (STCH) site leadership were tasked to develop an innovative care model. The central aim was quality improvement and patient safety optimization in the emergency department (ED) utilizing a nurse practitioner (NP) model. They developed 3 pillars: collaboration, multidisciplinary approach, and integration with the plan of improving patient satisfaction and ensuring no patient gets lost to follow up. NPs work in the STCH ED and the NP led Emergency Department Transition (EDT) Clinic in Ambulatory Care. In the ED NPs provide direct clinical care, judicious review of DI and microbiology reports, and care coordination for patients at risk of lost to follow up. The EDT clinic is an innovative NP lead clinic with the purpose of providing timely, high-quality follow up care for ED patients. Methods: Data for the service delivery indicators came from data repository and manual data collection looking at the following outcomes: timely review of DI/micro results; decreased ED visits for non-urgent/emergent issues; safe transitions in care and improved patient satisfaction. Quantitative data from service delivery, patient and surveys were analyzed using Microsoft Excel and SPSS 19. Results: From June 2016 to January 2017 ED NPs at STCH reviewed 3000 positive microbiology reports and made 517 f/u calls to those patients, and reviewed 3181 DI results. This has freed up approximately 2 hrs per day of ED physician time. When NPs were working in the ED, the number of patients who left without treatment (LWT) was approximately 50% less, and improved STCH ED wait times to be among the lowest in the Edmonton Zone. From June 2016 to January 2017, EDT NPs completed 837 patient visits; 371 letters to family physicians (FPs); 215 referrals; and connected 520 patients to a new FP. Patient satisfaction survey show 88-90% of the patients were satisfied with their care. Conclusion: NPs are integral members of the ED team at STCH, providing direct clinical care and several valuable follow up services for ED patients. The EDT clinic provides urgent follow up for ED patients unable to get a timely appointment with their FP or no access to primary care. The clinic also prevents unnecessary returns to ED, and aids to bridge ED services to family physicians or specialist. NPs are the common thread through all departments at STCH, contributing to quality improvement and high patient satisfaction.

P154: Exploring health care connections and transitions in care for patients presenting to emergency departments with acute wheezing illnesses

Introduction: Asthma and/or chronic obstructive pulmonary disease (COPD) exacerbations often result in emergency department (ED) visits. This study examined the health-related personnel providing regular care to patients with asthma and/or COPD, as well as, explored the coordination of care between the ED and outpatient settings. Methods: Descriptive cross-sectional examination of patients presenting with asthma and/or COPD exacerbations to two EDs in Edmonton between August and December 2017. Using patient interview methods information on demographics, established health care connections and health system use was collected; information on consultations, disposition and referrals was collected through chart review methods. Results: A total of 50 patients were recruited (14 patients with asthma and 36 patients with COPD). Most of the patients with asthma were female (64%) and their median age was 36 years (interquartile range [IQR]: 29, 46); sex was evenly distributed among the patients with COPD and their median age was 68 years (IQR: 61, 78). The majority reported having a family doctor (86% of the patients with asthma and 94% of the patients with COPD). On the day of admission to the ED, 29% of the patients with asthma visited their family doctor while 42% of the patients with COPD visited their Respirologist; these doctors referred >70% of the patients to the ED. While in the ED, consultations were requested in 21% of the patients with asthma (all to Pulmonary) and in 78% of the patients with COPD (evenly divided between Medicine and Pulmonary). Transition coordinators and social workers were involved in the ED care of <15% of the patients with COPD. Most patients with asthma were discharged home (86%) and 64% of the patients with COPD were hospitalized. After discharge, 14% of the patients with asthma and 50% of the patients with COPD were referred to specialized care. Conclusion: While the study patients with asthma and COPD had different health professionals providing regular care to their respiratory conditions, they both sought care before presenting to the ED. More health professionals were involved in the ED care of patients with COPD than of those with asthma. This study provided important information to support further research projects exploring ways to effectively and efficiently improve the delivery, comprehensiveness and utilization of health care services.

P082: Kingston emergency department utilization of adults who have experienced adverse childhood experiences

Introduction: It is critical for planning, clinical care and resource optimization to understand patterns of emergency department (ED) utilization. Individuals who have experienced adverse childhood experiences (ACE) are known to have more unhealthy behaviors and worse health outcomes as adults and therefore may be more frequent ED users. Adverse childhood experiences include physical, sexual and emotional abuse or neglect, substance abuse in the family, witnessing violence, having a parent incarcerated or parents getting divorced or separated. To date there are few studies exploring the relationship between ACE and ED utilization. Methods: This a mixed qualitative and quantitative study. It includes analysis of data collected through a survey, a retrospective chart review and focus group discussions. The survey was administered to a convenience sample of adult patients (CTAS 2 -5) presenting to EDs in Kingston Ontario, and consisted of two validated tools that measured exposure to ACE and resiliency. Demographic data and ED utilization frequency for 12 months prior to the index visit were extracted from an electronic medical record for each patient completing the survey. A sample of participants with a high ACE burden (ACE score > 4) were invited to participate in focus groups to explore their experiences of care in the ED. Demographic, ED utilization and health status data were summarized and statistically significant patterns between high ACE and lower ACE patients were determined using Chi2t or t-tests. Transcripts from the focus groups were thematically analyzed using NVivo software by 2 independent researchers. Results: 1693 surveys were collected, 301 (18%) were deemed to have a high ACE score, data analysis is ongoing. The primary outcome is the relationship between ACE and the frequency of ED utilization among adult patients presenting to EDs in Kingston, ON. Secondary outcomes include evaluating the role of resilience as a potential mitigating factor, describing the demographics of high ACE burden frequent ED visitors, and the experiences of care for individuals with high ACE burden in the ED. These outcomes will be utilized to inform hypotheses for future studies and potential interventions aimed at optimizing ED utilization and patient care experience. Conclusion: This study provides novel insight into the relationship between ACE burden and ED utilization while also describing the demographics and experiences of care for ED patients with a high ACE score. Data analysis is on-going.

An Exploration of Emergency Physicians' Attitudes Toward Patients With Substance Use Disorder.

Much is known about some healthcare professionals' attitudes toward patients with substance use disorders, but few studies have specifically looked at emergency department (ED) physicians. Individuals with substance use disorders are more likely to be people who chronically, frequently use the ED, and thus ED physicians are in a unique position to provide early identification and intervention for people struggling with addiction. The purpose of this study was to understand ED physicians' attitudes toward patients with substance use disorder with the aim of decreasing stigma and improving the care of ED patients with substance use disorder. An anonymous Qualtrics survey was emailed to 115 emergency physicians in the Johns Hopkins Health System. The survey contained (1) demographics and (2) the medical condition regard scale, http://links.lww.com/JAM/A67. Participants were offered a $10 Amazon gift card to complete the survey. The response rate was 50% (n = 58) and the completion rate was 43% (n = 50). Physicians had lower regard for patients with substance use disorders than other medical conditions with behavioral components. Of note, 54% of respondents indicated that they at least "somewhat agree" that they "prefer not to work with patients with substance use who have pain." A significant portion of our study population had low regard for patients with substance use. Future research is needed to determine significant contributing factors and develop interventions to mitigate negative attitudes among ED physicians toward patients with substance use disorder.

Clinical pharmacy services in the emergency department

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.

Lean thinking in emergency departments: concepts and tools for quality improvement.

The lean approach is a viable framework for reducing costs and enhancing the quality of patient care in emergency departments (EDs). Reports on lean-inspired quality improvement initiatives are rapidly growing but there is little emphasis on the philosophy behind the processes, which is the essential ingredient in sustaining transformation. This article describes lean philosophy, also referred to as lean, lean thinking and lean healthcare, and its main concepts, to enrich the knowledge and vocabulary of nurses involved or interested in quality improvement in EDs. The article includes examples of lean strategies to illustrate their practical application in EDs.

Complex Regional Pain Syndrome in Children

This article presents an overview of emergency department care for patients with complex regional pain syndrome (CRPS). The pathophysiology and natural history of CRPS are explained, and multiple methods of diagnosis are also explored. A thorough background of the natural history of CRPS is given, and a table is included that outlines the stages of CRPS and how they can be used to understand how advanced the disease is. Treatment of CRPS and where to refer patients for continued and definitive treatment are described. In addition to physical therapy and pain psychology, multiple medication management strategies are also discussed.

192 Strengthening Emergency Care Operations in East Africa: Implementation of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya

Implementation of triage systems standardizes and improves patient care in emergency departments (ED). Kenyatta National Hospital (KNH), the largest public tertiary hospital in Kenya, is both resource limited and without ED-specific triage protocols. To standardize the approach to triage through implementation of the South African Triage Scale (SATS). We aimed to 1) assess the reliability of triage decisions among nurses and doctors following an educational intervention, 2) analyze validity of the SATS at KNH’s ED, comparing prior triage practice with the newly implemented triage protocol. We conducted a two-part prospective observational study to assess the reliability and validity of the SATS as implemented in the ED at KNH. In part one, we assessed the percent agreement with an expert standard (a consensus-derived correct triage category) using previously validated vignettes via paper test administered to health care workers before and after an educational intervention. In part two, we assessed the validity of the SATS in predicting patient disposition outcomes through a retrospective, systematic sampling of triage charts, one month pre- and post-implementation. 104 paper tests were included for reliability analysis. Percent agreement with the expert standard increased after the educational intervention, from 47% to 64% exact agreement (p<0.0001), and from 89% to 97% agreement allowing for a one-level discrepancy in triage ratings (p<0.0001). 2420 total charts were analyzed for validity before and after SATS implementation. There was no significant change in percent of patients under-triaged or over-triaged before and after the implementation. However, neither the proportion of over-triage (12.8%) nor the proportion of under-triage (2.7%) exceeded the American College of Surgeons-Committee on Trauma thresholds (25-35% and 5%, respectively). Health care workers who received the educational intervention achieved high levels of agreement with expert, demonstrating that the intervention is contextually appropriate and represents an ongoing medical education opportunity. SATS scores performed well in predicting outcomes with low levels of both under and over-triage, confirming SATS as a locally appropriate triage system for standardizing care at a major East Africa emergency department.

A Bayesian system to detect and characterize overlapping outbreaks

Outbreaks of infectious diseases such as influenza are a significant threat to human health. Because there are different strains of influenza which can cause independent outbreaks, and influenza can affect demographic groups at different rates and times, there is a need to recognize and characterize multiple outbreaks of influenza. This paper describes a Bayesian system that uses data from emergency department patient care reports to create epidemiological models of overlapping outbreaks of influenza. Clinical findings are extracted from patient care reports using natural language processing. These findings are analyzed by a case detection system to create disease likelihoods that are passed to a multiple outbreak detection system. We evaluated the system using real and simulated outbreaks. The results show that this approach can recognize and characterize overlapping outbreaks of influenza. We describe several extensions that appear promising.

Implementation of the Theory of Planned Behavior to Promote Compliance with a Chlorhexidine Gluconate Protocol

IntroductionBlood cultures are critical values for identifying the source of an infection in patients seeking medical treatment for an acute illness. False-positive cultures can negatively influence patient care when physicians use inaccurate information to prescribe treatment. Inaccurate prescribed treatment negatively influences the quality of patient care related to prolonged medical treatment and hospital stay and unnecessary repetition of diagnostic tests. PurposeThe purpose of this project was to determine if blood culture contamination rates would be decreased if improved availability of CHG products was provided in all emergency department patient care areas would reduce the contamination rates of blood cultures. MethodologyThe Theory of Planned Behavior provided the theoretical framework for this descriptive correlational project to examine barriers to following the procedural guidelines to cleanse venipuncture sites with a chlorhexidine gluconate (CHG) product before venipuncture Alcohol preparation pads were removed from the emergency department and a CHG product packaged similar to the alcohol preparation pads was placed in the department procedure trays and bedside carts. ResultsDuring the first 2 weeks of the pilot project, blood culture contamination rates were reduced from 4.5% to 1.5%. The following month, rates remained low at 1.9%. ConclusionPlacement of CHG products at the bedside will improve patient safety and quality of care by reducing the incidence of inaccurate diagnosis and treatment based on false-positive blood cultures.

LO44: Initial validation of the core components in the SHoC-Hypotension Protocol. What rates of ultrasound findings are reported in emergency department patients with undifferentiated hypotension? Results from the first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial

Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP&amp;lt;100 or shock index&amp;gt;1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.

LO45: Does the use of point of care ultrasonography improve survival in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial

Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP&amp;lt;100 or shock index&amp;gt;1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.

LO07: Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial

Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP&amp;lt;100 mmHg or shock index &amp;gt;1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.

Identification, Assessment, and Management of Suicide Risk in Emergency Departments: Significant Updates in Research and Practice

It is estimated that emergency departments (EDs) could prevent 5% of all suicide attempts and 8% of suicide deaths, making EDs a critical setting in which to identify individuals at risk for suicide and to intervene to mitigate the risk. The goal of this review was to detail recent advances in the identification, assessment, and management of suicide risk in emergency medicine and to provide best practice recommendations for these processes. Advances in caring for patients who present to EDs with suicide risk include improved workflows and tools for ED providers to identify, assess, and manage suicide risk, increased patient-centeredness and quality of ED care for patients at risk of suicide, and shifting beliefs of ED providers regarding the feasibility of integrating the assessment and management of suicide risk into emergency care. ED suicide prevention efforts have notably changed in recent years. Strategies for universal screening, secondary screening tools, and evidence-based workflows for the management of suicide risk all show potential for feasibly addressing suicide risk in EDs. Effective implementation of evidence-based practices is necessary as integrating these new practices requires significant change in the clinical practice and culture of many EDs.

The use of computerized clinical decision support systems in emergency care: a substantive review of the literature.

: This paper provides a substantive review of international literature evaluating the impact of computerized clinical decision support systems (CCDSSs) on the care of emergency department (ED) patients. : A literature search was conducted using Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase electronic resources, and gray literature. Studies were selected if they compared the use of a CCDSS with usual care in a face-to-face clinical interaction in an ED. : Of the 23 studies included, approximately half demonstrated a statistically significant positive impact on aspects of clinical care with the use of CCDSSs. The remaining studies showed small improvements, mainly around documentation. However, the methodological quality of the studies was poor, with few or no controls to mitigate against confounding variables. The risk of bias was high in all but 6 studies. : The ED environment is complex and does not lend itself to robust quantitative designs such as randomized controlled trials. The quality of the research in ∼75% of the studies was poor, and therefore conclusions cannot be drawn from these results. However, the studies with a more robust design show evidence of the positive impact of CCDSSs on ED patient care. This is the first review to consider the role of CCDSSs in emergency care and expose the research in this area. The role of CCDSSs in emergency care may provide some solutions to the current challenges in EDs, but further high-quality research is needed to better understand what technological solutions can offer clinicians and patients.

Barcode technology and emergency medicine pharmacy

AbstractBackgroundThe emergency medicine pharmacist (EMP) represents a new field of pharmacy practice in many hospitals and at St Vincent's Hospital Sydney the EMP visits the emergency department (ED) daily Monday to Wednesday (MW), with other pharmacists providing services on Thursday and Friday. Because newer practice areas need to justify services, barcode technology offers an efficient means to collect service provision data.AimThe aim of this study was to determine whether barcode scanning could be used to efficiently describe and quantify EMP services, including the time involved in undertaking activities.MethodThe Activity BarCoding (ABC®) system is a commercially available software package that involves using a portable barcode scanner to collect and present data as an activity profile. The ABC® data generated for the EMP were reviewed for September 2012–March 2013.ResultsThe MW EMP spent 124.5 h undertaking ED clinical care activities (1.48 h/day). In all, 634 patients were seen and, on average, the MW EMP spent 8.94 min with each patient (range: 6.97–9.93 min). Both clinical and non‐clinical activities could be described, with time allocation and interventions easily quantifiable.DiscussionBarcode technology accurately recorded the variety of and time required for activities performed by the EMP and demonstrated EMP involvement in ED patient care. It provides information that describes and quantifies EMP services that can be used for business case development and service improvements. Further standardisation of activity and intervention categories will enhance data collection, benchmarking possibilities and multicentre research.

Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis

Asthma is the most common chronic paediatric disease treated in the emergency department (ED). Rapid corticosteroid administration is associated with improved outcomes, but our busy ED setting has made it...

Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda.

Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

136 Impact of Electronic Clinical Decision Support on Initial Site of Care for Emergency Department Patients With Acute Pulmonary Embolism

136 Impact of Electronic Clinical Decision Support on Initial Site of Care for Emergency Department Patients With Acute Pulmonary Embolism

Sex-related Differences in Emergency Department Renal Colic Management: Females Have Fewer Computed Tomography Scans but Similar Outcomes.

Sex-related differences occur in many areas of medicine. Emergency department (ED) studies have suggested differences in access to care, diagnostic imaging use, pain management, and intervention. We investigated sex-based differences in the care and outcomes for ED patients with acute renal colic. This was a multicenter population-based retrospective observational cohort study using administrative data and supplemented by structured chart review. All patients seen in Calgary Health Region EDs between January 1 and December 31, 2014, with an ED diagnosis of renal colic based on the following ICD-10 codes were eligible for inclusion: calculus of kidney (N200), calculus of ureter (N201), calculus of kidney with calculus of ureter (N202), hydronephrosis with renal and ureteral calculous obstruction (N132), unspecified renal colic (N23), and unspecified urinary calculus (N209). ED visit data and test results were accessed in the regional ED clinical database. Stone characteristics were captured from diagnostic imaging reports. Regional hospital databases were used to identify subsequent ED encounters, hospital admissions, and surgical procedures within 60days. Outcomes were stratified by sex. The primary outcome, intended as a marker of overall effectiveness of ED care, was the unscheduled 7-day ED revisit rate among patients who were discharged home after their index ED visit. Secondary outcomes included ED pain management as reflected by administration of narcotics or intravenous nonsteroidals, the performance of advanced imaging-either ultrasound (US) or computed tomography (CT), and the proportion of patients who required hospitalization or surgical intervention within 60days. From January 1 to December 31, 2014, a total of 3,104 eligible patients were studied: 1,111 women (35.8%) and 1,993 men (64.2%). Baseline characteristics, access times, analgesic use, and admission rates were similar in both groups. Men were more likely to have CT (68.9% vs. 58.5%, difference=10.4%, 95% confidence interval [CI]=6.8 to 14.0) while women were more likely to have US (20.8% vs. 9.6%, difference=11.2%, 95% CI=8.4 to 13.9). At 7days, 17.9% of women and 19.0% of men who were discharged after their index ED visit required an ED revisit (difference=1.1%, 95% CI=-2.8 to 4.9). Men were more likely to be hospitalized at 7days (9.8% vs. 6.5%, difference=3.3%, 95% CI=0.6 to 6.0). This study shows greater reliance on US in females but no other sex-specific differences in the management of ED patients with acute renal colic. Higher CT use in men was not associated with improved outcomes, and we found no important differences in access to care, diagnostic or treatment intensity, or revisit rates as a marker of care effectiveness.