Prior Emergency Department Visits Research Articles

Pregnant and bleeding: A model to assess factors associated with the need for emergency care in early pregnancy.

To assess the prevalence of Critical or Emergent patient classification among pregnant patients presenting to the Emergency Department (ED) and to identify characteristics that discriminate between patients requiring Emergency care from those who can be safely triaged to the ambulatory setting. In this cross-sectional study conducted in 3 urban EDs, patients under 16 weeks gestation who presented with bleeding and/or cramping completed a 7-item questionnaire. We compared baseline clinical variables and survey responses among patients classified as Critical or Emergent per the American Board of Emergency Medicine's patient acuity definitions with those classified as Lower Acuity to identify independent risk factors for outcomes. Of 484 participants, 21 (4.3%) were classified as Critical or Emergent and required interventions. While no demographic characteristics differentiated Critical patients from Lower Acuity patients, survey questions associated with a higher likelihood of emergency intervention included history of prior ectopic pregnancy (OR 8.7, 95% CI 3.2-23.5) heavy bleeding in the past two hours (OR 11.8, 95% CI 3.8-36.1), as well as having made a prior ED visit in the current pregnancy (OR 1.9, 95% CI 0.7-5.1). Joint consideration of these risk factors in a multivariable model performed well at discriminating between Critical and Lower Acuity patients with an area under the ROC curve of 0.82 (95% CI 0.71-0.93). Patients with a history of ectopic pregnancy, heavy bleeding in the past two hours, and/or prior presentation to the ED in the current pregnancy had the highest risk of needing emergency-level care. The vast majority of patients presenting to the ED with early pregnancy complaints were discharged without intervention.

Derivation of the Pediatric Acute Gastroenteritis Risk Score to Predict Moderate-to-Severe Acute Gastroenteritis.

Although most acute gastroenteritis (AGE) episodes in children rapidly self-resolve, some children go on to experience more significant and prolonged illness. We sought to develop a prognostic score to identify children at risk of experiencing moderate-to-severe disease after an index emergency department (ED) visit. Data were collected from a cohort of children 3 to 48 months of age diagnosed with AGE in 16 North American pediatric EDs. Moderate-to-severe AGE was defined as a Modified Vesikari Scale (MVS) score ≥9 during the 14-day post-ED visit. A clinical prognostic model was derived using multivariable logistic regression and converted into a simple risk score. The model's accuracy was assessed for moderate-to-severe AGE and several secondary outcomes. After their index ED visit, 19% (336/1770) of participants developed moderate-to-severe AGE. Patient age, number of vomiting episodes, dehydration status, prior ED visits, and intravenous rehydration were associated with MVS ≥9 in multivariable regression. Calibration of the prognostic model was strong with a P value of 0.77 by the Hosmer-Lemenshow goodness-of-fit test, and discrimination was moderate with an area under the receiver operator characteristic curve of 0.68 (95% confidence interval [CI] 0.65-0.72). Similarly, the model was shown to have good calibration when fit to the secondary outcomes of subsequent ED revisit, intravenous rehydration, or hospitalization within 72 hours after the index visit. After external validation, this new risk score may provide clinicians with accurate prognostic insight into the likely disease course of children with AGE, informing disposition decisions, anticipatory guidance, and follow-up care.

A comparison of administrative claims-based risk predictors for pediatric asthma.

Head-to-head comparisons are needed to determine the most accurate and appropriate administrative claims-based exacerbation risk predictor for emergency department (ED) visits and hospitalizations among children with asthma. Retrospective cohort study. We analyzed 2013-2014 MarketScan Medicaid data. Children aged 2 to 17 years were included. Seven risk predictors were compared for accuracy in predicting 3-month subsequent ED visits/hospitalizations for asthma: 3-month rolling asthma medication ratio (AMR), Healthcare Effectiveness Data and Information Set (HEDIS) criteria, revised HEDIS criteria, quarterly short-acting β-agonist (SABA) claims, prior ED visit, prior hospitalization, and prior ED visit or hospitalization. Sensitivity, specificity, positive and negative predictive value (NPV), and percentage of population identified as high risk were compared for each risk predictor utilizing the McNemar test to identify statistically significant differences in risk prediction accuracy. A total of 214,452 children were included; the mean age was 7.8 years. HEDIS and revised HEDIS identified prohibitively large cohorts as high risk (67% and 48%, respectively). For the remaining measures, the NPV range is narrow (97%-99%), indicating high performance at identifying patients who would not benefit from intervention. The ED visit and ED/hospitalization measures have superior sensitivities (44% and 49%, respectively) compared with pharmacy claims-based measures (AMR [5%] and SABA count [10%]). Pharmacy claims-based measures identify a smaller proportion of patients as high risk and maintain high NPV. Pharmacy-based asthma exacerbation risk predictors such as the AMR and SABA count can rule out low-risk patients with a high degree of specificity and NPV, which is a primary goal of real-time risk monitoring in pediatric asthma.

Abstract 9307: A Heart of Gold: A Case Report of Massive Pericardial Effusion Secondary to Cholesterol Pericarditis

A case of rare cholesterol pericarditis that developed over 12 years resulting in a massive pericardial effusion containing cholesterol crystals is described. A 41-year-old homeless man with history of polysubstance intravenous drug abuse and upper respiratory and soft-tissue infections presented with evidence of recurrent left lower extremity cellulitis, mild shortness of breath, and palpitations. Physical exam demonstrated soft-tissue infection, marked tachycardia and distant heart sounds on auscultation, and jugular venous distention. Unexpectedly, pulse-oximetry plethysmographic waveforms revealed pronounced respirophasic variability and pulsus paradoxus of 14 mmHg. Electrocardiogram demonstrated low voltage and electrical alternans. A transthoracic echocardiogram revealed a large pericardial effusion and findings consistent with tamponade physiology, such as elevated respiratory variation in mitral inflow velocity. Emergent pericardiocentesis yielded 3.6 L of fluid characterized by glittering, gold paint-like appearance and a cell count predominated by macrophages, leading to a provisional diagnosis of cholesterol pericarditis. This was confirmed by polarized light microscopy demonstrating cholesterol crystals. Retrospective review of prior emergency department visits revealed a 12-year development of the effusion, beginning with symptoms, imaging, and labs consistent with a presumably instigating viral respiratory illness. Over time, progressive enlargement and evidence of chronic pericarditis were demonstrated by chest x-ray and electrocardiography, while the effusion remained undiagnosed. Following improvement in his symptoms after pericardiocentesis, the patient deferred pericardial window and definitive surgical management with pericardiectomy. Given his high risk for recurrent cardiac tamponade, he was given clear return precautions and is now followed on an outpatient basis. The diverse etiologies of cholesterol pericarditis, such as hypothyroidism, tuberculosis, and rheumatoid arthritis, that guided the workup for this patient, and the pathophysiology of this disease and its treatment options, are reviewed.

46 External Validation of a Singapore Electronic Health Record-Based Emergency Department Admission Prediction Model in a North American Setting

Models for predicting admission of patients from an emergency department (ED) have been suggested as a device for reducing ED crowding; however, such models are not widely implemented. The objective of this study is to validate an existing ED admission model on data from an outside hospital, as a first step to identifying a generalizable means to develop such models. Previously, an ED admission model was developed on retrospective observational data at a large urban hospital in Singapore. Data from the electronic health record (EHR) of a tertiary medical center in Durham, North Carolina (NC ED) were curated and transformed to align closely with the features of the Singapore model. A stepwise logistic regression model was built on these features to predict the probability of inpatient admission for patients presenting to the NC ED at the time of triage. A randomly selected 30% subset of the data was withheld from training and used to validate the model. Performance metrics were compared to those attained by the Singapore team. A total of 60, 064 encounters from January to December 2019 were included in the analysis; these patients had an admission rate of 28.2%. Variables used for modeling were first identified by the Singapore team and included age, sex, day of week, Emergency Severity Index (ESI), race, shift time, mode of arrival, time of year, postal code, fever status, and number of prior ED visits. The model we trained on the NC ED EHR data, using the features of the Singapore team’s model, had an area under the ROC curve (AUROC) of 0.821 (95% CI, 0.804-0.837), comparable to the AUROC of 0.825 (95% CI, 0.824-0.827) obtained by the Singapore team’s on their data. The most significant features associated with discharge included an ESI Score above 3 and ED arrival by law enforcement; the most significant features associated with admission included ESI Score below 3, fever status, and advanced age. We have been able to map elements from the NC ED EHR to the Singapore triage model elements to develop a model that performs comparably. Thus, a general method for building simple, effective ED admission models at various independent hospitals is attainable and scalable.

Evaluation of Penicillin Allergy Prevalence and Antibiotic Prescribing Patterns for Patients within the Emergency Department

As the point of entry into healthcare for many patients, the emergency department (ED) is an ideal setting in which to assess penicillin (PCN) allergies. An estimated 10% of the United States population has a reported PCN allergy; however, few studies have evaluated the prevalence and impact of PCN allergies on antibiotic selection within the ED. Patients with a documented PCN allergy are more likely to be exposed to costly alternative broad-spectrum antibiotics that have higher rates of adverse events, including C. difficile infections. We sought to determine the prevalence of PCN allergies within the UNC Medical Center ED. Key secondary outcomes included the percentage of patients with a documented PCN allergy who (1) received alternative antibiotics (carbapenems, aztreonam, fluoroquinolones, clindamycin, vancomycin), (2) received β-lactam antibiotics and experienced an allergic reaction during their ED visit, and/or (3) had received a β-lactam antibiotic during a past hospitalization or ED visit without their chart being appropriately updated. A retrospective evaluation included patients aged >18 years with a documented PCN allergy who were discharged from the ED between January 1, 2017, and December 31, 2019. Over the study period, there were 14,635 patient encounters with a documented PCN allergy that comprised 8,573 unique patients. The prevalence of PCN allergies was 14.3% for all ED encounters. PCN allergy–labeled patients received alternative antibiotics in 59.4% of ED encounters in which antibiotics were prescribed. Of the 454 β-lactam antibiotics (62 penicillins, 380 cephalosporins, 12 carbapenems) administered to PCN allergy-labeled patients within the ED, there were zero allergic reactions. Also, 18.6% of PCN allergy-labeled patients had received and tolerated a β-lactam antibiotic during prior hospitalizations or ED visits (1.7% penicillins, 14.4% cephalosporins, 2.6% carbapenems) without appropriate updated documentation to reflect β-lactam antibiotic tolerance. These findings confirm the utilization of non–β-lactam antibiotics in PCN allergy-labeled patients, highlighting the importance of accurate and updated allergy documentation in the electronic medical record. These findings also demonstrate the need for improved allergy documentation and protocols to proactively assess penicillin allergy labels while in the ED.Funding: NoDisclosures: None

GRACE-recurrent low-risk chest pain: A user's guide.

GRACE-recurrent low-risk chest pain: A user's guide.

Impact of Limited English Proficiency on Definitive Care in Pediatric Appendicitis

BackgroundLimited English proficiency (LEP) is associated with decreased access to healthcare. We hypothesized that LEP children with appendicitis would experience more delays in care than EP children. MethodsRetrospective review of patients <18 y presenting to a tertiary pediatric hospital July 2014-July 2019 with appendicitis. LEP patients were compared to EP patients. The primary outcome was appendiceal perforation. Secondary outcomes included prior pediatrician or emergency department (ED) visits without definitive management, duration of symptoms, length of stay (LOS), initial operative or non-operative management, time from presentation to operation and return to the ED within 30 d. Multivariable regression was performed to evaluate LEP as a predictor of study outcomes. ResultsA total of 893 patients with appendicitis were identified, 15.6% (n = 140) had LEP. On multivariate regression LEP was not a significant predictor of appendiceal perforation (AOR 1.20, 95% CI 0.79, 1.80, P = 0.390). LEP was a significant predictor of a prior ED or pediatrician visit without definitive management (AOR 2.05, 95 % CI 1.05, 3.98, P= 0.034) and longer LOS (Coefficient 1.01, 95% CI 0.41, 1.61, P= 0.001). LEP was associated with a minimal increase in duration of pain prior to presentation that was not clinically significant and was not associated with initial operative or non-operative management or a significantly longer time between presentation and operation. ConclusionsLEP children did not experience higher rates of appendiceal perforation at our institution, but were more frequently initially evaluated by a pediatrician or at an ED and discharged without definitive management and had longer LOS.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities.

In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language. A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test. Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers. Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

Determinants of asthma-related emergency department return visits in adults: A population-based study

RATIONALE: Emergency department (ED) return-visit rates provide a measure of the quality of acute asthma care. OBJECTIVES: We sought to assess the impact of patient and site characteristics, including asthma management strategies, on return visits within 72 hours, prior to implementation of a standardized adult ED asthma care pathway in EDs throughout Ontario, Canada. METHODS: This population-based cohort study utilized comprehensive administrative health data from the Institute for Clinical Evaluative Sciences for adults 20 to 64 years old who had at least one ED visit for asthma from April 1, 2006 to March 31, 2008. Detailed information on ED management strategies was available on a subset of 37 sites whose staff attended pathway implementation workshops. MEASUREMENTS AND MAIN RESULTS: A total of 41,140 asthma visits to 167 EDs were analyzed. Most patients (64.8%) were triaged as high acuity and the majority (92.8%) were discharged. The return-visit rate was 2.8%. Female gender, younger age, higher acuity, leaving the ED before visit completion and prior admission or ED visit for asthma were associated with increased odds of a return visit. The only management strategy associated with reduced ED visits was access to 24-hour peak flow measurement. CONCLUSION: This study identified well-recognized patient- and hospital-level risk factors for return ED visits. Access to peak flow monitoring was the only protective management strategy found. As many ED asthma service and care gaps exist, province-wide implementation of a standardized care pathway may greatly impact ED management and improve patient outcomes including return ED visits.

Emergency Department Utilization Among People Living With HIV on Chronic Opioid Therapy.

Chronic pain among people with HIV (PWH) is a driving factor of emergency department (ED) utilization, and it is often treated with chronic opioid therapy (COT). We conducted a cross-sectional analysis of a prospective observational cohort of PWH on COT at 2 hospital-based clinics to determine whether COT-specific factors are associated with ED utilization among PWH. The primary outcome was an ED visit within 12 months after study enrollment. We used stepwise logistic regression including age, gender, opioid duration, hepatitis C, depression, prior ED visits, and Charlson comorbidity index. Of 153 study participants, n = 69 (45%) had an ED visit; 25% of ED visits were pain-related. High dose opioids, benzodiazepine co-prescribing, and lack of opioid treatment agreements were not associated with ED utilization, but prior ED visits (p = 0.002), depression (p = 0.001) and higher Charlson comorbidity score (p = 0.003) were associated with ED utilization. COT-specific factors were not associated with increased ED utilization among PWH.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children.

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Racial and ethnic disparities in the delayed diagnosis of appendicitis among children.

Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). This was a 3-year multicenter (seven EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, other) with 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). Of 7,298 patients with appendicitis and documented race/ethnicity, 2,567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; adjusted odds ratio [aOR]= 1.21 [95% confidence interval {CI}= 1.01 to 1.45]). A total of 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR= 1.81 [95% CI= 1.09 to 2.98]). Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR= 0.41 [95% CI= 0.18 to 0.96]) or definitive imaging (e.g., ultrasound/computed tomography/magnetic resonance imaging; 10.3% vs. 35.9%; aOR= 0.15 [95% CI= 0.05 to 0.50]) during prior visits. In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis and, thus, may contribute to higher perforation rates demonstrated among minority children.

Association of inappropriate polypharmacy with emergency department visits in older patients receiving anti-neoplastic therapy: a population-based study.

We aimed to investigate the prevalence and predicting factors of inappropriate polypharmacy including potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) and their associations with emergency department (ED) visits in older Korean patients receiving anti-neoplastic therapy. We identified older patients receiving anti-neoplastic therapy in 2016 from the National Health Claims database. We investigated the prevalence of inappropriate polypharmacy comprising PIMs and DDIs in geriatric patients according to the 2019 American Geriatrics Society Beers Criteria® and chemotherapeutic DDIs using LexicompOnlineTM and Micromedex®. A nested case-control study was conducted to evaluate the associations between inappropriate polypharmacy and ED visits during anti-neoplastic therapy. Multivariate logistic regressions were performed after adjusting for age, sex, cancer diagnosis, prior ED visits, Charlson Comorbidity Index, and type of anti-neoplastic therapy. Inappropriate polypharmacy, its subtype PIMs, geriatric, and chemotherapeutic DDIs were observed in 85.4%, 80.4%, 17.3%, and 37.9% of the 21,956 patients receiving anti-neoplastic therapy, respectively. After adjusting for confounding factors, the presence of inappropriate polypharmacy (adjusted odds ratio (aOR) 2.15, 95% confidence interval (CI) 1.97-2.35), 2 or more PIMs (aOR 1.85, 95% CI 1.68-2.02), 2 or more chemotherapeutic DDIs (aOR 2.88, 95% CI 2.54-3.28), and geriatric DDIs (aOR 1.61, 95% CI 1.43-1.80) increased the likelihood of ED visits during anti-neoplastic therapy. This nationwide study showed that inappropriate polypharmacy was prevalent and increased the risk of ED visits in older patients receiving anti-neoplastic therapy. Study findings suggested a need to implement deprescribing strategies in this population.

A Machine Learning Approach to Predicting Readmission or Mortality in Patients Hospitalized for Stroke or Transient Ischemic Attack

Readmissions after stroke are not only associated with greater levels of disability and a higher risk of mortality but also increase overall medical costs. Predicting readmission risk and understanding its causes are thus essential for healthcare resource allocation and quality improvement planning. By using machine learning techniques on initial admission data, this study aimed to develop prediction models for readmission or mortality after stroke. During model development, resampling methods were implemented to balance the class distribution. Two-layer nested cross-validation was used to build and evaluate the prediction models. A total of 3422 patients were included for analysis. The 90-day rate of readmission or mortality was 17.6%. This study identified several important predictive factors, including age, prior emergency department visits, pre-stroke functional status, stroke severity, body mass index, consciousness level, and use of a nasogastric tube. The Naïve Bayes model with class weighting to compensate for class imbalance achieved the highest discriminatory capacity in terms of the area under the receiver operating characteristic curve (0.661). Despite having room for improvement, the prediction models could be used for early risk assessment of patients with stroke. Identification of patients at high risk for readmission or mortality immediately after admission has the potential of enabling early discharge planning and transitional care interventions.

Risk factors of hospitalization for any medical condition among patients with prior emergency department visits for mental health conditions

BackgroundThis longitudinal study identified risk factors for frequency of hospitalization among patients with any medical condition who had previously visited one of six Quebec (Canada) emergency departments (ED) at least once for mental health (MH) conditions as the primary diagnosis.MethodsRecords of n = 11,367 patients were investigated using administrative databanks (2012–13/2014–15). Hospitalization rates in the 12 months after a first ED visit in 2014–15 were categorized as no hospitalizations (0 times), moderate hospitalizations (1–2 times), and frequent hospitalizations (3+ times). Based on the Andersen Behavioral Model, data on risk factors were gathered for the 2 years prior to the first visit in 2014–15, and were identified as predisposing, enabling or needs factors. They were tested using a hierarchical multinomial logistic regression according to the three groups of hospitalization rate.ResultsEnabling factors accounted for the largest percentage of total variance explained in the study model, followed by needs and predisposing factors. Co-occurring mental disorders (MD)/substance-related disorders (SRD), alcohol-related disorders, depressive disorders, frequency of consultations with outpatient psychiatrists, prior ED visits for any medical condition and number of physicians consulted in specialized care, were risk factors for both moderate and frequent hospitalizations. Schizophrenia spectrum and other psychotic disorders, bipolar disorders, and age (except 12–17 years) were risk factors for moderate hospitalizations, while higher numbers (4+) of overall interventions in local community health service centers were a risk factor for frequent hospitalizations only. Patients with personality disorders, drug-related disorders, suicidal behaviors, and those who visited a psychiatric ED integrated with a general ED in a separate site, or who visited a general ED without psychiatric services were also less likely to be hospitalized. Less urgent and non-urgent illness acuity prevented moderate hospitalizations only.ConclusionsPatients with severe and complex health conditions, and higher numbers of both prior outpatient psychiatrist consultations and ED visits for medical conditions had more moderate and frequent hospitalizations as compared with non-hospitalized patients. Patients at risk for frequent hospitalizations were more vulnerable overall and had important biopsychosocial problems. Improved primary care and integrated outpatient services may prevent post-ED hospitalization.

A randomized trial of iPad distraction to reduce children's pain and distress during intravenous cannulation in the paediatric emergency department.

We compared the addition of iPad distraction to standard care, versus standard care alone, to manage the pain and distress of intravenous (IV) cannulation. Eighty-five children aged 6 to 11 years requiring IV cannulation (without child life services present) were recruited for a randomized controlled trial from a paediatric emergency department. Primary outcomes were self-reported pain (Faces Pain Scale-Revised [FPS-R]) and distress (Observational Scale of Behavioral Distress-Revised [OSBD-R]), analyzed with two-sample t-tests, Mann-Whitney U-tests, and regression analysis. Forty-two children received iPad distraction and 43 standard care; forty (95%) and 35 (81%) received topical anesthesia, respectively (P=0.09). There was no significant difference in procedural pain using an iPad (median [interquartile range]: 2.0 [0.0, 6.0]) in addition to standard care (2.0 [2.0, 6.0]) (P=0.35). There was no significant change from baseline behavioural distress using an iPad (mean ± SD: 0.53 ± 1.19) in addition to standard care (0.43 ± 1.56) (P=0.44). Less total behavioural distress was associated with having prior emergency department visits (odds ratio [95% confidence interval]: -1.90 [-3.37, -0.43]) or being discharged home (-1.78 [-3.04, -0.52]); prior hospitalization was associated with greater distress (1.29 [0.09, 2.49]). Significantly more parents wished to have the same approach in the future in the iPad arm (41 of 41, 100%) compared to standard care (36 of 42, 86%) (P=0.03). iPad distraction during IV cannulation in school-aged children was not associated with less pain or distress than standard care alone. The effects of iPad distraction may have been blunted by topical anesthetic cream usage. ClinicalTrials.gov: NCT02326623.

Patient characteristics associated with improvements in asthma control and reduction in emergency department visits for older adults with asthma

Objective To identify patient characteristics associated with improvements in asthma control among older adults with asthma. Methods Secondary analysis of data from a randomized controlled trial of an asthma self-management support intervention for adults ages 60 and older with moderate-severe persistent asthma (n = 391). We tested the association of baseline patient characteristics with reduced emergency department (ED) visits and improvement in asthma control equal to or exceeding the minimal clinically important difference (MCID) in asthma control test (ACT) scores (3.0) 12 months. Results At baseline, the mean age was 68 years, 15.0% were male, 30.3% were black, and 56.5% were Hispanic. Patients with a history of ED visits in the 12 months preceding study enrollment were significantly more likely to experience an ED visit during the study period (adjusted odds ratio [AOR] 6.92, 95% confidence interval [CI] 2.18–21.9, p < .0001). Similarly, those with poorer asthma control (baseline ACT scores <13) had greater odds of achieving improved asthma control (AOR 13.7, 95% CI 5.32–35.1, p < .0001). No other variables had statistically significant associations with the outcomes. Conclusions Low scores on the asthma control test and prior ED visits for asthma are strong correlates of later clinically meaningful changes in asthma control among older adults. Health systems preparing for population management of patients with asthma ought to consider incorporating serial collection of data on the ACT into the monitoring and management of older asthmatics, a high-risk patient population.

Predictors of future acute asthma visits among children receiving guideline recommended emergency department discharge management

Background Asthma emergency department (ED) visits remain frequent among children, prompting ongoing pursuit of preventative strategies. Objective We identified factors associated with future acute asthma ED visits among children who had already received guideline recommended discharge management following a prior asthma ED visit. Methods We performed a retrospective cohort study of children ages 1–17 years with a first asthma ED visit to the Children’s Hospital of Eastern Ontario in Canada between September 2014–August 2015. Children who received recommended discharge management including an inhaled corticosteroids prescription and/or an asthma action plan were included. We used multivariable logistic regression to identify factors associated with a future acute asthma visits one year following the first ED visit. Results Among 909 children with a first asthma ED visit, 24% had a future acute asthma visit within one year. Future acute asthma visits were more likely in children with a nut/peanut allergy (OR 1.76, 95% CI: 1.15, 2.70), higher severity symptoms (OR 2.04, 95% CI: 1.23, 3.39), a primary care physician (OR 2.23, 95% CI: 1.26, 3.93), or a prior diagnosis of asthma (OR 1.53, 95% CI: 1.03, 2.28). Conclusion Children at risk for repeat acute asthma ED visits despite having a primary care provider and receiving recommended discharge management at their first ED visit can be identified by factors such as having a nut/peanut allergy, a prior asthma diagnosis, and higher severity symptoms at ED presentation. These factors can be used to target more intensive preventative interventions to those most in need.

Association between unintentional injuries and self-harm among adolescent emergency department patients

BackgroundUnintentional injury, a leading cause of morbidity among adolescents, may also be a risk factor for deliberate self-harm. To inform clinical and public health prevention efforts in adolescent populations, we examined whether distinct subtypes of unintentional injury were differentially associated with deliberate self-harm. MethodsStatewide, all-payer, individually linkable administrative data on adolescent patients presenting to any California emergency department (ED) in 2010 (n = 490,071) were used to investigate longitudinal associations between subtypes of unintentional injury and deliberate self-harm. Adolescents aged 10–19 years presenting with unintentional drug poisoning, other poisoning, fall, suffocation, or cutting/piercing injuries formed the exposure groups; adolescents presenting with unintentional strike injuries formed the primary referent group. Study patients were followed back in time (2006–2009) to compare the groups' odds of a prior ED visit for deliberate self-harm, as well as forwards in time (2010–2015) to compare their risks of subsequent self-harm. ResultsUnintentional drug-poisoning injury was strongly associated with increased likelihood of ED visits for deliberate self-harm, assessed both retrospectively (adjusted OR = 4.52; 95% confidence interval [CI] = 3.08, 6.64) and prospectively (adjusted RR = 3.74; 95% CI = 3.03, 4.60). Positive associations with odds of prior self-harm and/or risk of subsequent self-harm were also observed for patients with unintentional non-drug poisoning, suffocation, and cutting/piercing injuries. ConclusionsCertain subtypes of unintentional injury, particularly drug poisoning, are strongly associated with risk for deliberate self-harm among adolescents, a finding with implications for targeting clinical assessment and intervention in emergency department settings. More research is needed to understand the mechanisms underlying these associations.