Emergency Department Patients Research Articles

379 Sex Differences in Testing for Pulmonary Embolism in Emergency Department Patients by Chief Complaint

379 Sex Differences in Testing for Pulmonary Embolism in Emergency Department Patients by Chief Complaint

494 Demographic and Societal Risk Factors for Pediculus-Associated Severe Anemia in Emergency Department Patients

494 Demographic and Societal Risk Factors for Pediculus-Associated Severe Anemia in Emergency Department Patients

Comparing the cardiorespiratory safety of parenteral olanzapine and benzodiazepines to parenteral haloperidol/droperidol and benzodiazepines in emergency department patients

IntroductionThis study sought to assess the cardiorespiratory safety of parenteral olanzapine and benzodiazepine combination treatment compared to parenteral droperidol or haloperidol and benzodiazepine combination treatment. Materials and methodsThis was a retrospective chart review conducted in adult emergency department patients who received intramuscular (IM) or intravenous (IV) droperidol, haloperidol, or olanzapine within one hour of IM or IV benzodiazepine. Patients were stratified into groups based on whether they received either olanzapine in combination with a benzodiazepine (n = 48) or droperidol or haloperidol in combination with a benzodiazepine (n = 48). ResultsPatients in each group had a decrease in their systolic blood pressure (SBP) after IM/IV olanzapine and IM/IV droperidol or haloperidol when used in combination with an IM/IV benzodiazepine ((Olanzapine + benzodiazepine (mmHg), median (IQR): Pre-SBP: 132 (117–151) vs. Post-SBP: 117 (99–131), p < 0.01) (Droperidol or haloperidol + benzodiazepine (mmHg), median (IQR): Pre-SBP: 138 (122–149) vs. Post-SBP: 106 (98–127), p < 0.01)). Both groups had similar percent SBP decreases post-combination treatment (Olanzapine + benzodiazepine (15.6 %) vs. Droperidol or haloperidol + benzodiazepine (15.2 %); p = 0.55). We did not observe any statistically significant between group differences for hypotension (Olanzapine + benzodiazepine: 1/48, 2.1 % vs. Droperidol or haloperidol + benzodiazepine: 3/48, 6.3 %; p = 0.62)), escalation in oxygen requirements (Olanzapine + benzodiazepine: 7/48, 14.6 %) vs. Droperidol or haloperidol + benzodiazepine: 5/48, 10.4 %; p = 0.76)), or intubation due to cardiorespiratory depression (Olanzapine + benzodiazepine: 0/0, 0 % vs. Droperidol or haloperidol + benzodiazepine: 0/0, 0 %; p = 1.00)). ConclusionThis study found decreases in SBP after administering parenteral olanzapine and parenteral droperidol or haloperidol in combination with a parenteral benzodiazepine. The percent change in SBP and the frequency of hypotensive episodes post-combination treatment were not different between groups. There were also no differences between groups in need of increased oxygen requirements post-combination treatment or need for intubation due to cardiorespiratory depression. This study suggests parenteral olanzapine in combination with a parenteral benzodiazepine may have comparable cardiorespiratory safety versus parenteral droperidol or haloperidol in combination with a parenteral benzodiazepine when treating agitation in the adult ED.

233 Medical Jargon Is Often Misunderstood by Emergency Department Patients

233 Medical Jargon Is Often Misunderstood by Emergency Department Patients

305 Accuracy of a Host Response Test for Diagnosis of Bacterial and Viral Infections and Prediction of Illness Severity in Emergency Department Patients Is Not Impacted by the Patient's Immune Status

305 Accuracy of a Host Response Test for Diagnosis of Bacterial and Viral Infections and Prediction of Illness Severity in Emergency Department Patients Is Not Impacted by the Patient's Immune Status

407 The Effect of Naloxone Administration on the Treat and Release Length of Stays in Emergency Department Patients With Suspected Opioid Overdoses

407 The Effect of Naloxone Administration on the Treat and Release Length of Stays in Emergency Department Patients With Suspected Opioid Overdoses

199 Evaluation of the Diagnostic Accuracy of Exhaled Nitric Oxide as a Marker of Infection and Sepsis in Emergency Department Patients

199 Evaluation of the Diagnostic Accuracy of Exhaled Nitric Oxide as a Marker of Infection and Sepsis in Emergency Department Patients

171 Cardiovascular Risks Associated With Cannabis Use in Emergency Department Patients

171 Cardiovascular Risks Associated With Cannabis Use in Emergency Department Patients

428 Self-Reported Readiness to Change Alcohol Use in Emergency Department Patients With Alcohol Use Disorder Predicts Successful Linkage to Treatment

428 Self-Reported Readiness to Change Alcohol Use in Emergency Department Patients With Alcohol Use Disorder Predicts Successful Linkage to Treatment

380 Rate of Comorbidities and Social Determinants of Health Barriers Among Emergency Department Patients With HIV

380 Rate of Comorbidities and Social Determinants of Health Barriers Among Emergency Department Patients With HIV

102 Leveraging Big Data in ACEP’s Emergency Medicine Data Institute Registry to Measure Syphilis and Sexually Transmitted Infection Co-Testing Rates Among Emergency Department Patients With Pregnancy Testing

102 Leveraging Big Data in ACEP’s Emergency Medicine Data Institute Registry to Measure Syphilis and Sexually Transmitted Infection Co-Testing Rates Among Emergency Department Patients With Pregnancy Testing

SUGAMMADEX SHOULD BE USED TO REVERSE ROCURONIUM IN EMERGENCY DEPARTMENT PATIENTS WITH NEUROLOGIC INJURIES

SUGAMMADEX SHOULD BE USED TO REVERSE ROCURONIUM IN EMERGENCY DEPARTMENT PATIENTS WITH NEUROLOGIC INJURIES

Handheld ultrasound versus standard machines for placement of peripheral IV catheters: A randomized, non-inferiority study

IntroductionUltrasound guided IV catheter (USGIV) access occurs frequently in Emergency Departments (EDs). This task is often performed using large, expensive, cart-based ultrasound systems (CBUS) which are frequently needed for other ED ultrasound functions and can be cumbersome to use and store. Handheld ultrasounds (HHUs) may be able to meet this need, but it is unknown if they function interchangeably with CBUS for USGIV placement. We performed a prospective, randomized, noninferiority study to compare the success rate of HHUs to CBUSs for placing USGIVs. MethodsED patients 18 and older needing an USGIV were approached for enrollment and randomized to receive an USGIV placed by CBUS or HHU. USGIVs were placed by any ED physician or nurse trained in placement. A placement was considered attempted upon needle entry into the skin. An USGIV was successful if it was immediately flushable with saline. Data was collected on the success of IV placement, number of attempts, IV and provider characteristics, patient demographics, and length of time the USGIV lasted. Demographics and operator and IV characteristics were analyzed using Pearson's Chi square, Fischer's Exact test, or Wilcoxon rank sum tests. Non-inferiority was assessed using the Farrington-Manning test. Results were approached per protocol and analyzed in R. Results312 patients were enrolled. Patient and IV characteristics were similar between groups. There was no difference in the number of successful USGIVs placed in either group (p≥0.9) with 146 in the CBUS group and 145 in the HHU group. There was no difference in the first attempt success rate between groups (p = 0.8) and HHU was noninferior to CBUS for successful USGIV placement (p = 0.0001). The rate of premature USGIV failure was similar between HHU and CBUS (4.0 % and 6.7 %). ConclusionHHU was noninferior to CBUS for successful USGIV placement. There was no difference in the rate of first attempt success at placement or USGIV survival to a patient's ED disposition between groups. No significant additional training was required for ED providers of all levels to use the HHUs.

Data-driven insights to increase utilization of an oncology acute care clinic.

342 Background: Cancer patients often use the emergency department (ED) for acute symptoms. Because of the frequency of non-emergent acute care, many practices have created non-ED sites of care, such as Oncology Acute Care (OAC). OAC clinics can manage urgent conditions, and have been shown to reduce ED visits, however, patient and practice factors may lead to underuse of these clinics. We aimed to increase OAC utilization at our safety-net system. Methods: Parkland Health is the safety-net system for Dallas County, caring for a primarily uninsured (70.0% Medicaid/charity care), minority population (60.4% Hispanic, 24.2% Black). We established an OAC in 2017: patients can call a dedicated triage line staffed by English and Spanish-speaking nurses, who schedule OAC visits as appropriate. Subsequent quantitative and qualitative research found that OAC was underused, but that many patients were simply unaware of the OAC. In early 2023, a monthly 20-member multidisciplinary workgroup was formed, including many frontline staff. Findings and ideas for improvement were reviewed with our Patient and Family Advisory Council. Implementation strategies were aimed at raising staff/provider awareness, streamlining patient education, and developing relevant process measures. Results: By Q1 2024, nurse call volume rose to 235, from 110 calls in Q3 of 2023. Patients began to call sooner upon symptom onset (50% of symptoms were more than 3 days old, compared to 55%); 51% were scheduled to the OAC on the same day. Nurses managed 34% of calls through telehealth. Lack of OAC availability resulted in ED referral for 4% of calls. There was an early downward trend in potentially avoidable ED visits (15% of chemotherapy infusions with an ED visit in 30 days in Q4 2023, down to 12.5% in Q1 2024). Conclusions: A data-driven, delivery research collaboration has been established to reduce avoidable ED care among adults receiving chemotherapy. This collaborative has been marshalling existing resources to serve a patient population that faces many challenges in optimizing their care. By piloting these implementation strategies, we are improving patient symptom management, and have created a platform for ongoing delivery innovation.

188 Temporal Impact of Hospice and Palliative Medicine Consults on End-of-Life Outcomes in Emergency Department and Hospitalized Patients

188 Temporal Impact of Hospice and Palliative Medicine Consults on End-of-Life Outcomes in Emergency Department and Hospitalized Patients

The High-Sensitivity HEART Pathway Safely Reduces Hospitalizations Regardless of Sex or Race in a Multisite Prospective US Cohort.

The high-sensitivity HEART pathway (hs-HP) risk stratifies emergency department (ED) patients with chest pain. It is unknown if its safety and effectiveness vary by sex or race. We conducted a subgroup analysis of the hs-HP implementation study, a pre-post interrupted time series at five US EDs. The pre-implementation period (January 2019 to April 2020) utilized the traditional HEART pathway with contemporary troponin (Siemens) and the post-implementation period (November 2020 to February 2022) used the hs-HP using hs-cTnI (Beckman Coulter). Patients were risk-stratified using the hs-HP to rule-out, observation, and rule-in groups. Safety and effectiveness outcomes were 30-day all-cause mortality or myocardial infarction (MI) and 30-day hospitalization. Twenty-six thousand and one hundred twenty-six patients were accrued (12 317 pre- and 13 809 post-implementation), of which 35.3% were non-White and 52.7% were female. Among 9703 patients with complete hs-HP assessments, 48.6% of White and 55.4% of non-White patients were ruled-out (p < 0.001). Additionally, 47.3% of males and 54.4% of females were ruled-out (p < 0.001). Among rule-out patients, 0.3% of White versus 0.3% of non-White patients (p = 0.98) and 0.3% of females versus males 0.3% (p = 0.90) experienced 30-day death or MI. Post-implementation, 30-day hospitalization decreased 17.2% among White patients (aOR 0.49, 95% CI: 0.45-0.52), 14.1% among non-White patients (aOR 0.53, 95% CI: 0.48-0.59), 15.6% among females (aOR 0.50, 95% CI: 0.46-0.54), and 16.6% among males (aOR 0.51, 95% CI: 0.47-0.56). The interactions for 30-day hospitalization between hs-HP implementation and race (p = 0.10) and sex (p = 0.69) were not significant. The hs-HP safely decreases 30-day hospitalizations regardless of sex or race. However, it classifies more non-White patients and women to the rule-out group.

PROPEL Discharge: An Interdisciplinary Throughput Initiative

BackgroundIncreased care demands at a healthcare institution led to strained resources, emergency department (ED) congestion, safety events, and patient and employee dissatisfaction. Moreover, high volumes of afternoon discharges contributed to limited early morning bed availability and admission bottlenecks. MethodsA 29-month pre-post design quality improvement project on 19 acute care, adult medicine units across two campuses at a large academic medical center was implemented to improve discharge timeliness, length of stay (LOS), and ED throughput by increasing pre-11:00 AM discharges. Based on Lean Six Sigma methodology, interventions included standardized interdisciplinary discharge processes and roles, processes to ensure performance data transparency and access, a recognition program, and a barrier tracking and mitigation process for continued improvements. ResultsDuring the intervention period, pre-11:00 AM discharges increased from 5.1% to 21.8% (p < 0.001), discharge orders were entered 42 minutes earlier (p < 0.001), patients were discharged 56 minutes earlier (p < 0.001), the percentage of discharges completed within 90 minutes from discharge order improved from 26.2% to 38.1% (p < 0.001), the percentage of discharges by 3:00 PM improved from 44.7% to 55.9% (p < 0.001), ED admissions arrived to units 44 minutes earlier (p < 0.001), median LOS decreased by 0.46 days (p < 0.001), median O:E LOS decreased by 0.05 (p < 0.001), and opportunity day reductions contributed to increased bed capacity of 18.84 beds per day. ConclusionEarly morning discharges are associated with improved patient throughput and are safe, achievable, and sustainable via interventions focused on frontline engagement, interdisciplinary collaboration, standardization, barrier mitigation, data accessibility, and accountability.

Rapid Electroencephalography and Artificial Intelligence in the Detection and Management of Nonconvulsive Seizures

Nonconvulsive status epilepticus is a commonly overlooked cause of altered mental status. This study assessed nonconvulsive status epilepticus prevalence in emergency department (ED) patients with acute neurologic presentations using limited electroencephalogram (EEG) coupled with artificial intelligence (AI)-enhanced seizure detection technology. We then compared the accuracy of the AI EEG interpretations to those performed by an epileptologist. In a prospective observational cohort analysis, adult patients with unexplained mental status changes identified by emergency physicians received expedited placement of a limited EEG. Data collected encompassed patient demographics, clinical history, EEG interpretations by the AI algorithm and epileptologists, treatments, and disposition determinations. There were 134 device applications on 132 patients (2 received the device twice) enrolled in the study, but 16 were missing data critical for identification or analysis and 9 did not meet the selection criteria. Of the 108 limited EEGs interpreted by an epileptologist, 69 were abnormal (diffuse slowing, highly epileptiform patterns, or spikes and sharps), 41 were normal, 5 were uninterpretable, and 3 captured episodes of seizure or status epilepticus. Limited EEG AI interpretation detected >90% seizure burden in 2 of 3 cases of seizure or status epilepticus as well as in 2 abnormal EEGs and 1 normal EEG, providing a sensitivity of 66.7% (95% confidence interval 9.4 to 99.2), a specificity of 97.0% (95% confidence interval 91.5 to 99.4), and a disease prevalence of 2.9%. Limited AI-enhanced EEG can detect nonconvulsive status epilepticus in the ED; however, the technology tended to overestimate seizure burden in our cohort. This study found a lower nonconvulsive status epilepticus prevalence compared to prior literature reports.

Extending emergency care beyond discharge: Piloting a virtual after care clinic.

Many unscheduled return visits to the emergency department (ED) stem from insufficient access to outpatient follow-up. We piloted an emergency medicine-staffed, on-demand, virtual after care clinic (VACC) as an alternative for discharged ED patients. Prospective cohort study of discharged ED patients who scheduled VACC appointments within 72hoursof index ED visit. We performed descriptive analyses and compared risks of ED return at 72hours and 30 days between patients who did/did not attend their appointment. From March to December 2022, 309 patients scheduled VACC appointments and 210 (68%) attended them. Patients who scheduled appointments were young (median 37 years), non-Hispanic white (80%), females (75%) with a primary care physicians (PCP) (90%), and commercial insurance (72%). Most VACC visits reinforced ED testing and/or treatment (64%) or adjusted medications (26%). VACC attendees were less likely to return to the ED within 72h (3.3%vs. 13.1%; risk difference 9.3% [95% confidence interval, CI 2.7%‒19.8%]) and 30 days (16.2%vs. 30.3%; risk difference 14.1% [95% CI 3.8%‒24.4%]) compared to those who scheduled but did not attend a VACC appointment.VACC attendance was associated with lower odds of 72-h (adjusted odds ratio [aOR] 0.0; 95% CI 0.0‒0.4) and 30-day (aOR 0.4; 95% CI 0.2‒0.7) return ED visits. In this pilot study, younger, white, female, commercially insured patients with a PCP preferentially scheduled VACC appointments. Among patients who scheduled VACC appointments, those who attended their appointments were less likely to return to the ED within 72hours and 30 days than those who did not.

Emergency practitioner-administered ultrasound nerve blocks in the emergency department: A retrospective analysis

Abstract OBJECTIVES: In the realm of acute pain management within emergency departments (EDs), the prevalent reliance on systemic analgesics, notably opioids, presents challenges due to associated risks and suboptimal efficacy. The emerging alternative of ultrasound-guided nerve blocks (USGNBs) has shown promise in prospective studies. However, the safety and efficacy of USGNBs when performed by emergency medicine practitioners remain largely unexplored, necessitating this study to address the research gap. The primary objectives of this study were to assess the efficacy of Emergency physician-performed USGNBs and changes in patient-reported pain (pre- and postnerve block) at 15 and 30 min. In addition, the time taken to perform nerve blocks, type of nerve block, frequency, indications, procedure time, and complications were all studied. METHODS: Conducted at a Tertiary Care Teaching Hospital in Pune, India, this single-center, retrospective observational study aimed to evaluate the effectiveness of USGNBs in the ED context. A retrospective analysis covered 274 emergency practitioner-performed USGNBs recorded from January 2022 to December 2023. Participants included consecutive ED patients consenting to nerve blocks, with practitioners utilizing bupivacaine (0.25%) and ropivacaine (0.25%) based on individual preferences. The study systematically recorded patient demographics, block types, indications, complications, and pre- and postpain scores on a Numerical Rating Scale. RESULTS: The study demonstrated a significant reduction in pain scores post-USGNB, with an average decrease of 2.9 ± 1.08 at 15 min and 5.8 ± 1.39 at 30 min. Commonly performed blocks included the femoral nerve, fascia iliaca, and serratus anterior, with notable pain relief in fracture management cases. Procedural durations varied, ranging from 2 to 12 min, while four complications were reported, including diaphragmatic paresis and arterial punctures during interscalene nerve block and fascia iliac compartment blocks, respectively. CONCLUSION: This extensive study in an academic ED setting supports the proficiency of emergency practitioners in performing USGNBs. The findings emphasize the transformative potential of USGNBs in academic ED pain management, showcasing notable pain reduction and minimal complications. These results advocate for the integration of advanced pain relief techniques into emergency medicine training programs, contributing to a comprehensive approach to acute pain management.