Primary Emergency Department Diagnosis Research Articles

2949. Emergency Department (ED) Discharge Antibiotic Prescription Review by Hospital Pharmacists at a Large Academic Medical Center

Abstract Background Direct patient discharge from the Emergency Department (ED) presents an ideal time to promote antimicrobial stewardship (AS). On March 1, 2021 we initiated a pilot program where ED pharmacists conduct a review of discharge antibiotic prescriptions (abx Rxs). The aim of this program is to ensure appropriate discharge abxs. Willow Pharmacy Epic Analysts, ED and AS pharmacists collaborated on this program which included Epic integration of Rx Discharge Track Board, ED Discharge InBasket, ED Discharge Rx iVent and AS-led education sessions. Methods Data for 2022 ED patients with discharge abx Rxs and iVents were extracted via Epic Reports. The first encounter per patient was included. We compared discharge abx Rxs and patient outcome data in Pharmacy vs No Pharmacy Review Groups (PRG, NPRG). Pharmacy iVents were used as a process measure. Results Among 5747 ED adult patients with discharge abx Rxs, 2638 (46%) were reviewed by pharmacy (PRG). PRG and NPRG had similar prevalence of chronic pulmonary disease (12% vs. 13%), diabetes mellitus (9% vs. 10%), malignancy (8% vs. 9%), peripheral vascular disease (6% vs. 8%), renal disease (4% vs. 5%), and HIV (1% vs. 2%) despite a difference in mean Charlson Comorbidity Index (0.64 vs 0.75, p< 0.01). The primary ED diagnosis was skin and soft tissue, urinary, intra-abdominal infections and pneumonia (25 vs 23%, 18 vs 17%, 8 vs 9%, 5 vs 6%, respectively all p=NS). In PRG, discharge abxs demonstrated an increase use of penicillin (26 vs 24%, p=0.017) and 2nd generation cephalosporin (17 vs 14%, p< 0.001). The PRG also decreased use of 3rd generation cephalosporin (11 vs 12%, p=NS), quinolones (6 vs 7%, p=NS) and clindamycin (1.7 vs 2.4%, p=NS). There was no difference in ED length of stay (LOS 4.8h in each group), C. difficile infection (CDI) within 8 weeks (0.1 vs 0.2%, p=NS), and 30 days repeat ED visit or inpatient admission with the same diagnosis as index ED encounter (2.8 vs 2.6%, p=NS). Pharmacists intervened in 10% (272/2638) of ED abx Rxs with 92% (249/272) acceptance rate. The top 3 pharmacy interventions were recommending alternative abx (42%), dose optimization (31%) and abx duration (6%). Conclusion Engaging pharmacists in ED discharge Rxs review resulted in use of narrower spectrum abx with lower CDI risk without any negative impact on ED LOS and clinical outcomes. Disclosures All Authors: No reported disclosures

Epidemiology and outcomes of emergency department visits in systemic lupus erythematosus: Insights from the nationwide emergency department sample (NEDS).

Systemic lupus erythematosus (SLE) patients are prone to frequent emergency department (ED) visits. This study explores the epidemiology and outcomes of ED visits by patients with SLE utilizing the Nationwide Emergency Department Sample (NEDS). Using NEDS (2019), SLE ED visits identified using ICD-10 codes (M32. xx) were compared with non-SLE ED visits in terms of demographic and clinical features and primary diagnoses associated with the ED visits. Factors associated with inpatient admission were analyzed using logistic regression. Variations in ED visits by age and race were assessed. We identified 414,139 (0.35%) ED visits for adults ≥ 18years with SLE. ED visits with SLE comprised more women, Black patients, ages 31-50years, Medicare as the primary payer, and had higher comorbidity burden. A greater proportion of Black and Hispanic SLE patients who visited the ED were in the youngest age category of 18-30years (around 20%) compared to White patients (less than 10%). Non-White patients had higher Medicaid utilization (27%-32% vs 19% in White patients). Comorbidity patterns varied based on race, with more White patients having higher rates of hyperlipidemia and ischemic heart disease (IHD) and more Black patients having chronic kidney disease (CKD), hypertension, and heart failure. Categorizing by race, SLE/connective tissue disease (CTD) and infection were the most prevalent primary ED diagnosis in non-White and White patients, respectively. Age ≥ 65years, male sex, and comorbidities were linked to a higher risk of admission. Black race (OR 0.86, p = .01) and lowest income quartile (OR 0.78, p = .003) had lower odds of inpatient admission. Infection and SLE/CTD were among the top diagnoses associated with ED visits and inpatient admission. Despite comprising a significant proportion of SLE ED visits, Black patients had lower odds of admission. While the higher prevalence of older age groups, hyperlipidemia, and IHD among White patients may partly explain the disparate results, and further study is needed to understand the role of other factors including reliance on the ED for routine care compared among Black patients, differences in insurance coverage, and potential socioeconomic biases among healthcare providers.

Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study.

The definition of non-specific presentation at a hospital emergency department (ED) has not yet been formally established. The purpose of this study was to assess the relationships between primary ED diagnoses identified by ICD-10 codes and ED length of stay (LOS). Over the course of three years, we examined 134,675 visits at a tertiary hospital. LOS was examined in groups with specific (internal, surgical, neurological, and traumatic diseases) and non-specific diagnoses. Our secondary objective was to measure LOS by age, day of the week, time of day, and season. The median LOS was 182 min (interquartile range: 99-264 min). LOS was 99 min in the traumatic group, while it was 132 min in the surgical group, 141 min in the non-specific group, 228 min in the internal medicine group, and 237 min in the neurological group. Other determinants of LOS were age, revisits, day of the week, and time of arrival-but not a season of the year. In the non-specific group (21% of all diagnoses), the percentage of hospitalizations was higher than in the specific groups. Our results suggest that in clinical practice, the non-specific group should be redefined to also encompass diagnoses from ICD-10 Chapter XXI (block Z00-Z99).

Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006-2020.

To evaluate the association of short-term exposure to overall fine particulate matter of <2.5 μm (PM2.5 ) and wildfire-specific PM2.5 with emergency department (ED) visits for headache. Studies have reported associations between PM2.5 exposure and headache risk. As climate change drives longer and more intense wildfire seasons, wildfire PM2.5 may contribute to more frequent headaches. Our study included adult Californian members (aged ≥18 years) of a large de-identified commercial and Medicare Advantage claims database from 2006 to 2020. We identified ED visits for primary headache disorders (subtypes: tension-type headache, migraine headache, cluster headache, and "other" primary headache). Claims included member age, sex, and residential zip code. We linked daily overall and wildfire-specific PM2.5 to residential zip code and conducted a time-stratified case-crossover analysis considering 7-day average PM2.5 concentrations, first for primary headache disorders combined, and then by headache subtype. Among 9898 unique individuals we identified 13,623 ED encounters for primary headache disorders. Migraine was the most frequently diagnosed headache (N=5534/13,623 [47.6%]) followed by "other" primary headache (N=6489/13,623 [40.6%]). For all primary headache ED diagnoses, we observed an association of 7-day average wildfire PM2.5 (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.95-1.44 per 10 μg/m3 increase) and by subtype we observed increased odds of ED visits associated with 7-day average wildfire PM2.5 for tension-type headache (OR 1.42, 95% CI 0.91-2.22), "other" primary headache (OR 1.40, 95% CI 0.96-2.05), and cluster headache (OR 1.29, 95% CI 0.71-2.35), although these findings were not statistically significant under traditional null hypothesis testing. Overall PM2.5 was associated with tension-type headache (OR 1.29, 95% CI 1.03-1.62), but not migraine, cluster, or "other" primary headaches. Although imprecise, these results suggest short-term wildfire PM2.5 exposure may be associated with ED visits for headache. Patients, healthcare providers, and systems may need to respond to increased headache-related healthcare needs in the wake of wildfires and on poor air quality days.

Characterization of potentially avoidable neurological emergency department visits at a large urban public hospital

This study characterized potentially avoidable neurological emergency department (ED) visits at a large urban public hospital. This was a retrospective review of Parkland Health (Dallas, TX) data from May 15, 2021, to July 15, 2021. The study population included encounters discharged home from the ED with any of the following: a primary neurological ED diagnosis, a neurological consultation in the ED, or a neurology clinic referral placed during the ED encounter. Neurovascular, strokelike, acute trauma, and nonneurological cases were excluded. The primary outcome was the number of ED visits by diagnosis category. A total of 965 ED discharge encounters met study criteria as potentially avoidable neurological ED visits, far higher than total neurology-related admissions over the same 2-month period. Headache (66%) and seizure/epilepsy (18%) syndromes were the most common. Thirty-five percent of all cases had neurology involvement in either the ED or the outpatient setting. This was lowest for headache (19%). The revisit rate within 3 months of the index ED visit was 29%, and it was highest for seizures/epilepsy (48%). Potentially avoidable nonvascular neurological ED visits occur frequently, especially for headache and seizure disorders. This study highlights the need for quality improvement and delivery innovation initiatives to optimize the site of care for patients with chronic neurological conditions.

Abstract 14227: Development of a Tool To Improve Risk Stratification of Patients With Atrial Fibrillation in the Emergency Department

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion

BackgroundPostoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use. MethodsSingle-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients’ age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression. ResultsOut of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001). ConclusionsMore than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Racial and demographic disparities in emergency department utilization for mental health concerns before and during the COVID-19 pandemic

This study investigated whether emergency department (ED) visits for mental health concerns increased during the COVID-19 pandemic, taking a health disparities lens. ED encounters from the only academic medical center in Mississippi were extracted from March-December 2019 and 2020, totaling 2,842 pediatric (ages 4–17) and 17,887 adult (ages 18–89) patients. Visits were coded based on primary ED diagnosis. For adults, there were fewer depression/anxiety ED visits during the pandemic, not moderated by any demographic factor, but no differences for serious mental illness or alcohol/substance use. For youth, there were significantly fewer ED visits for behavior problems during the pandemic among children in the lower socioeconomic status (SES) category; there were no differences for depression/anxiety. Regardless of year, adults in the lower SES category were more likely to visit the ED for mental health, Black adults were less likely to visit the ED for depression/anxiety or alcohol/substance use, and Black children were less likely to visit the ED for behavioral concerns. Results suggest that access to outpatient and telehealth services remains critical for mental health care during the pandemic and underline the importance of race- and SES-related factors in use of the ED for mental health concerns beyond the pandemic.

Rationale and design of the comparison of outcomes and access to care for heart failure (COACH) trial: A stepped wedge cluster randomized trial

Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF. We will evaluate an intervention comprised of 2 complementary components: (1) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and (2) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death. Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: (1) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or (2) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation. This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.

Emergency department visits among patients transported by law enforcement officers.

Law enforcement officers frequently encounter people with health conditions. We sought to estimate the rates, diagnoses, and characteristics of emergency department (ED) visits among patients transported directly by law enforcement. We analyzed statewide North Carolina Emergency Department data for adults, aged 18+ years, from 2009 to 2016. We estimated transport rates using census data; categorized primary ED diagnoses into 13 major and 8 substituent categories; compared county transport rates by rurality; and examined patient characteristics. There were 136,240 patients transported by law enforcement; annual rates increased from 186.9 (per 100,000 adult residents) in 2009 to 279.2 in 2016. Among visits, 67.7% were among men, the median age was 37 years, and 20.4% resulted in a hospital admission. Most common primary diagnoses were Mental Health Diagnoses (43.1%)-including Schizophrenia and other Psychotic Disorders (7.6%), Mood Disorders (9.7%), and Alcohol and Substance Use (10.7%)-followed by Injury and Poisoning (12.4%) and Circulatory conditions (4.1%). Involuntary commitments constituted 22% of all visits. The median transport rate in rural counties, 291.1, was 2 times that of large metro counties, 145.1. The visit rate increased by nearly 50% during the study period, with the highest rates in rural counties. Many transports were for Mental Illness and involuntary commitments. The relatively common occurrence of law enforcement transports suggests the need for greater research to understand factors influencing law enforcement transport decisions, the impact of these transports on patient health and safety, and the repercussions on patient care of a growing officer presence in EDs.

Methamphetamine-Related Emergency Department Visits Requiring Psychiatric Admission: A Retrospective Cohort Study

The aim of this study was to determine if certain clinical or sociodemographic characteristics were associated with a higher likelihood of psychiatric admission for stimulant-related emergency department (ED) visits. Using administrative data collected by the Kingston Health Sciences Centre Emergency Department Information System was used to assemble a retrospective cohort study. The primary outcome measure was ED disposition (admission vs. discharge), while covariates included age, sex, primary ED diagnosis, mode of ED arrival, and length of ED stay. Statistical analysis was conducted using bivariate and multivariate logistic regression in SAS. Over a 4-year period, 915 stimulant-related presentations were recorded (64.5% male, mean age 32.8 years). Nearly 15% of all visits required psychiatric admission. Time trend analysis showed a significant increase in the number of visits by fiscal year. The most common stimulant-related presentations were stimulant intoxication (32.8%) and stimulant-induced psychosis (23.0%). Significant predictors of psychiatric admission were arrival by police (adjusted odds ratio [AOR] = 1.90), older age (AOR = 1.03), longer length of ED stay (AOR = 1.03), and more severe triage score (AOR = 0.4). Certain clinical and sociodemographic characteristics are associated with psychiatric admission among individuals who present to the ED with methamphetamine-related chief complaints. These characteristics could later be used to improve clinical risk profiles and ED triage algorithms that can help identify patients who may require enhanced community care and those who may benefit from psychiatric admission.

93 An Epidemiological Study of Falls Presentations in the Elderly in a Regional Hospital

Abstract Aims To identify the characteristics and outcomes for older people who present to a regional hospital Emergency Department (ED) with a fall and to determine factors associated with admission and representation. Methods In this retrospective cohort study, data for patients with falls (&amp;gt;= 65 years) who presented to the ED was collected from 01/06/2014-30/11/2014 and 01/06/2015-30/11/2015 Falls episodes were reviewed for: Place and time of fall; polypharmacy and medication subtypes; comorbidity count; cognitive impairment; ED assessments; Major injury; Representations and readmissions within 90 days and review by Geriatric Emergency Department Intervention (GEDI) nurse. Characteristics of persons admitted and discharged after a fall was compared. Characteristics associated with representation and admissions were reviewed with a logistic regression analysis. Results Episodes of older people with falls presenting to the ED (n=280) had high prevalence of complex multimorbidity (82.8%) and polypharmacy (66.4%), more so in episodes resulting in admission and representation. Most falls occurred indoors, presented to the ED during daytime and arrived by ambulance. 50% of episodes resulted in admission. Investigations in the ED regardless of need for discharge or admission showed only 4% having postural blood pressures recorded, 22% had a physiotherapy review and 31% had a GEDI nurse review. Though 86% of falls episodes had a primary ED diagnoses recorded as falls-related injury, two thirds of admitted episodes did not have a diagnosis of major injury. There were 80 representations. Polypharmacy and prior ED presentations were associated with representation. Comorbidity, previous falls and major injury were associated with admission. Conclusions Older adults who present to the ED after a fall were complex and had high rates of admission and representation. The focus of clinical assessments was on injuries. This profile enables building future interventions that address risk factors and falls prevention.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population

This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Who Makes the Diagnosis? A Retrospective Observational Study Comparing the Emergency Department Initial Diagnosis and the Internal Medicine Discharge Diagnosis

Background: Despite the central role of Internal Medicine (IM) in emergency admission management, both users and health planners do not seem to recognize the distinct features of the activities relative to IM. According to the Literature, the role of IM is characterized by: (1) Acute, critical, multiple pathology and complex patient management; (2) Difficult clinical diagnosis; (3) Individuation of priorities; (4). Hospitalterritory pathways promoting integration of diverse specialist activities. Objective: To determine the proportion of correct and missed emergency department (ED) diagnoses compared to IM discharge diagnoses. Methods: ED diagnoses and hospital IM discharge diagnoses were compared. By using the consensus among experts method a diagnosis evaluation grid was formed. Diagnosis was defined as follows: (1) The “gold standard” diagnosis (correct diagnosis), according to ICD10 (10th International Classification of Diseases and Related Health Problems), independently made by two experienced IM specialists and reported in the discharge letter. (2) ED diagnosis made by the Emergency Physician and reported in the patient acceptance or transfer record to the Internal Medicine Unit; (3) Priority Error: the correct diagnosis appears as a secondary diagnosis in the ED diagnosis; (4) Incomplete diagnosis: diagnostic orientation without a precise diagnosis; (5) Diagnosis Error: the correct diagnosis was not made in the ED. The first 13 diagnoses made in ED are defined as the most frequent in number within the sample being examined. Results: 317 non trauma patients presenting to the ED from June to September 2016 and admitted to the INI (Italian Neurotraumatology Institute) IM department were included for final analysis. The final diagnosis at IM discharge was taken to be the correct “gold standard” diagnosis. In 180 patients (56,7%) this corresponded with the primary ED diagnosis, in 104 patients (32,8%) the diagnosis was missed and in the remaining 10.5%, the diagnosis (33 patients) was incomplete or a priority error occurred. The most frequent final diagnoses were cardiac failure (n =53), pneumonia (n= 43), TIA (Transient Ischemic Attack) (n=31); respiratory failure (n=28); COPD (Chronic Obstructive Pulmonary Disease) (n=21), correctly diagnosed in the ED in 37, 26, 19, 20, and 11 patients, respectively. Conclusion: Patients presenting to ED with acute symptoms represent a diagnostic challenge that in 43.3% of cases is explained by the clinical activity carried out by the Internal Medicine specialist during hospitalization. The study confirms the central role of Internal Medicine in defining the correct diagnosis in acute and complex patients. It is likely time to instigate awareness campaigns for patients and policy makers promoting the central role of Internal Medicine in hospital organization and hospital-territory integration and to duly recognize the complexity of IM activity through the endorsement of appropriate DRGs (Diagnosis Related Groups) in the Medical Area.

Patient, provider, and environmental factors associated with adherence to cardiovascular and cerebrovascular clinical practice guidelines in the ED

ObjectivesMyocardial infarction and stroke are two of the leading causes of death in the U.S. Both diseases have clinical practice guidelines (CPGs) specific to the emergency department (ED) that improve patient outcomes. Our primary objectives were to estimate differences in ED adherence across CPGs for these diseases and identify patient, provider, and environmental factors associated with adherence. MethodsDesign: Retrospective study at 3 hospitals in Colorado using standard medical record review. Population: Consecutive adults (≥18) hospitalized for acute coronary syndrome (ACS), ST-elevation myocardial infarction (STEMI), or acute ischemic stroke (AIS), who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. Outcome: ED adherence to the CPG (primary); in-hospital mortality and length-of-stay (secondary). Analysis: Multivariable logistic regression using generalized estimating equations was used. ResultsAmong 1053 patients, ED care was adherent in 84% with significant differences in adherence between CPGs (p<0.001) and across institutions (p=0.04). When patients presented with atypical chief complaints, the odds of receiving adherent care was 0.6 (95% CI 0.4–0.9). When the primary ED diagnosis was associated but not specific to the CPG, the odds of receiving adherent care was 0.5 (95% CI 0.3–0.9) and 0.3 (95% CI 0.2–0.5) for unrelated primary diagnoses. ConclusionsAdherence to ED CPGs for ACS, STEMI and AIS differs significantly between cardiovascular and cerebrovascular diseases and is more likely to occur when the diagnosis is highly suggested by the patient's complaint and acknowledged as the primary diagnosis by the treating ED physician.

Identifying Variability in Patient Characteristics and Prevalence of Emergency Department Utilization for Mental Health Diagnoses in Rural and Urban Communities.

In order to redirect at-risk patients to more appropriate, cost-effective behavioral health care, research must identify the prevalence, and common characteristics, of patients presenting to the emergency department (ED) for mental disorders. Are large, small, and/or isolated rural patients presenting to the ED for mental disorders in greater proportion than urban ED patients? Analyses included data from the Health Care Cost and Utilization Project State Emergency Department Databases (2013) provided by 7 states, covering all Census regions. Variables included patient demographics, ZIP code, and primary and secondary ED diagnoses. ZIP codes were linked to the Rural-Urban Commuting Areas, aggregating into 4 categories. Prevalence rates were compared within and between groups (P < .05). Nearly 1 in 20 ED visits carried a primary/secondary diagnosis of mental disorder. Large, small, and isolated rural patients were not more likely than urban patients to present to the ED for mental disorders. Large, small, and isolated rural residents diagnosed with a primary/secondary mental disorder in the ED were more likely than urban to be female, 65 years of age or older, covered by Medicaid or Medicare, and dual eligible. The top 3 diagnoses for mental disorders in the ED were anxiety-state, unspecified; depressive disorder; and suicidal ideation. EDs treating large, small, or isolated rural patients with mental disorders are more likely to treat populations identified in the literature at greater risk of preventable visits, readmitting, and more costly care. Recommendations are made for policy, community interventions, workforce, and training.

Toxicological Emergencies in the Resuscitation Area of a Pediatric Emergency Department: A 12-Month Review.

Few studies of children with toxicological emergencies describe those undergoing acute resuscitation, and most describe exposures to single agents. We describe a 12-month sample of patients evaluated in the resuscitation area of a pediatric emergency department (ED) for a toxicological emergency. We conducted a retrospective chart review of patients in a high-volume, academic pediatric ED. We identified patients evaluated in the ED resuscitation area for toxicological exposure and conducted structured chart reviews to collect relevant data. For all variables of interest, we calculated standard descriptive statistics. Of 2999 patients evaluated in the resuscitation area through 12 months (March 2009 to April 2010), we identified 80 (2.7%) whose primary ED diagnosis was toxicological. The mean age was 11.4 years. Eighty-six percent of patients were triaged to the resuscitation area for significantly altered mental status. The most frequent single exposures were ethanol (25%), clonidine (10%), and acetaminophen (5%). At least 1 laboratory test was performed for almost all patients (97%). Interventions performed in the resuscitation area included intravenous access placement (97%), activated charcoal (20%), naloxone (19%), and endotracheal intubation (12%). Eighty-two percent of patients were admitted to the hospital; 37% to the intensive care unit. No patients studied in this sample died and most received only supportive care. In a high-volume pediatric ED, toxicological emergencies requiring acute resuscitation were rare. Ethanol and clonidine were the most frequent single exposures. Most patients received diagnostic testing and were admitted. Further studies are needed to describe regional differences in pediatric toxicological emergencies.

LO50: Headache presentations to emergency departments in Alberta: understanding investigative approaches

Introduction: Headaches are a common emergency department (ED) presentation. The objective of this study was to characterize headache presentations in Alberta over a five-year period and explore the proportion of patients with potentially severe pathology. Methods: Administrative health data for Alberta (years 2011-2015) were obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (&amp;gt;17 years) headache presentations (ICD-10-CA: G43, G44, R51). Patients with a primary or secondary diagnosis code of headache were eligible for inclusion in the study. Exclusions were made using the following criteria: 1) sites without computed tomography (CT) scanners; 2) presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1; 3) patients with trauma or external mechanism of injury (e.g., ICD-10-CA codes S,T,V,W,X,Y); and 4) presentations receiving an enhanced/contrast CT (head). NACRS data were linked with a provincial diagnostic imaging data. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, 98,333 presentations were made by 66,970 patients (~0.3 presentations per patient per year; equivalent to one presentation every 3.4 years). Headache presentations increased from 15,643 in 2011 to 21,636 in 2015. The median age was 38 years (IQR: 29, 51 years); more patients were female (69.3%), had a CTAS score of 3 (55%) and arrived at the ED without ambulance (90.3%). The majority of patients had a primary ED diagnosis of headache (88%) and the most common co-diagnosis was benign hypertension (2.8%). Additional diagnoses indicating severe or pathological headaches, included: stroke (0.63%), subarachnoid hemorrhage (0.43%), infection (i.e., meningitis) (0.11%), and other brain hemorrhages (0.08%). Overall, the ED management of approximately 25% of presentations involved a head CT. Most patients were discharged from the ED (89.4%) after a median length of stay of 3.5 hours (IQR: 2.1, 5.2 hours). Conclusion: Headache-related ED presentations are increasing in Alberta, yet few severe/pathological diagnoses are being identified. Efforts to ensure appropriateness of head CT ordering could reduce exposure to ionizing radiation, improve patient flow and reduce health care costs; this imaging represents a target for future interventions.

Factors associated with patients who prefer HIV self-testing over health professional testing in an emergency department-based rapid HIV screening program.

Kiosk-facilitated HIV self-testing has been shown to be accurate and well accepted by emergency department (ED) patients. We investigated factors associated with patients who preferred self-testing over testing performed by health professionals in an ED-based HIV screening program. This opt-in program evaluation studied 332 patients in an inner-city academic ED from February 2012 to April 2012, when a kiosk-based HIV self-testing program was standard of care. The first kiosk in the 2-stage system registered patients and assessed their interest in screening, while the second kiosk gathered demographic and risk factor information and also provided self-testing instructions. Patients who declined to self-test were offered testing by staff. Broad eligibility included patients aged 18-64 years who were not critically ill, English-speaking, able to provide informed consent, and registered during HIV program operational hours. Data were analyzed using descriptive statistical analysis and Chi squared tests; 160 (48.2%) of 332 patients consenting to testing chose to use a kiosk to guide them performing self-testing. Patients aged 25-29 years and those whose primary ED diagnosis was not infectious disease-related were more likely to prefer HIV self-testing (OR = 2.19, 95% CI: 1.17-4.10; OR = 1.79, 95% CI: 1.03-3.12). HIV self-testing in the ED could serve as a complementary testing approach to the conventional modality.

A Population-Based Analysis of Outcomes in Patients With a Primary Diagnosis of Hypertension in the Emergency Department

Patients treated primarily for hypertension are common in the emergency department (ED). The outcomesof these patients who were given a primary ED diagnosis of hypertension have not been described at a population level. In thisstudy, we describe the characteristics and outcomes of these patients, as well as changes over time. This retrospective cohort study used linked health databases from the province of Ontario, Canada, to assess ED visits made between April 1, 2002, and March 31, 2012, with a primary diagnosis of hypertension. We determined the annual number of visits, as well as the age- and sex-standardized rates. We examined visit disposition and assessed mortality outcomes and potential hypertensive complications at 7, 30, 90, and 365 days and at 2 years subsequent to the ED visit. There were 206,147 qualifying ED visits from 180 sites. Visits increased by 64% between 2002 and 2012, from 15,793 to 25,950 annual visits, respectively. The age- and sex-standardized rate increased from 170 per 100,000 persons to 228 per 100,000 persons during the same period, a 34% increase. Eight percent of visits ended in hospitalization, but this proportion decreased from 9.9% to 7.1% during the study period. Mortality was very low: less than 1% within 90 days, 2.5% within 1 year, and 4.1% within 2 years. Among subsequent hospitalizations for potential hypertensive complications, stroke was the most frequent admitting diagnosis, but the frequency was still less than 1% at 1 year. Together hospitalizations for stroke, heart failure, acute myocardial infarction, atrial fibrillation, renal failure, hypertensive encephalopathy, and dissection were less than 1% at 30 days. The number of visits made primarily for hypertension has increased significantly during the last decade. Although some of the increase is due to aging of the population, other forces are contributing to it as well. Subsequent mortality and complication rates are low and have declined. With current practice patterns, the feared complications of hypertension are extremely infrequent.