Emergency Department Providers Research Articles

Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management.

Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.

Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia.

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Why Veterans Choose VA Versus non-VA Emergency Care: A Qualitative Study.

In ensuring the timely delivery of emergency care to Veterans, Veterans Affairs (VA) offers both emergency care services in its own facilities and, increasingly, purchases care for Veterans in non-VA (community) emergency department (ED) settings. Although in recent years emergency care coverage has become the single largest contributor to VA community care spending, no study to date has examined Veteran decision-making as it relates to ED setting choice. The purpose of this study is to identify and describe reasons why Veterans choose VA versus non-VA emergency care settings. Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured telephone interviews from December 2018 through March 2020 with 50 Veterans to understand the factors Veterans consider when deciding where to obtain ED care. Interviews were audio-recorded and transcribed verbatim. We conducted a directed content analysis of interview transcripts and developed a matrix to summarize and categorize each Veteran's decision-making process to compare participants and to identify common patterns. When choosing between VA and non-VA-EDs, Veterans described 3 distinct patterns of decision-making: (1) choosing the closest ED (often community) for acute conditions; (2) traveling farther for VA care due to preference and financial coverage; and (3) selecting VA when both types of ED care were equidistant. Perceptions of community resources, condition-specific needs, financial considerations, and personal preferences dominated the decision-making. For example, most Veterans (74%) rated their acuity as high, and self-perceived severity/urgency of their condition was the most cited factor influencing where Veterans decided to go for ED care. Our qualitative results help provide insight into how and why Veterans choose to seek emergency care. As the number of Veterans treated in non-VA EDs continues to rise, VA and non-VA ED providers as well as policy makers may benefit from understanding the challenges Veterans face when making this decision.

Development of a Curriculum for Emergency Physicians to Teach Transesophageal Echocardiography for Cardiac Arrests: A Kern Six-Step Model

BACKGROUND: The Kern model facilitates the development, implementation, and evaluation of successful educational systems in medicine. It involves six steps that link curricular content to health care needs. One such need is the design of a curriculum to teach emergency physicians practical use of focused transesophageal echocardiography employing a limited number of views for management of out-of-hospital cardiac arrests. The objective of this analysis was to describe the components of such a curriculum based on a Kern model that could be employed to train emergency department providers in this diagnostic modality. METHODS: We predicated our analysis on the American College of Emergency Physicians’ recommendations and goals for use of transesophageal echocardiography to guide emergency department cardiac arrest resuscitation. We then detailed an asynchronous pre-didactic learning experience followed by a synchronous didactic and simulation-based curriculum to teach emergency physicians how to acquire and interpret images for this purpose based upon steps set forth by a Kern model. RESULTS: The component steps in designing a curriculum constructed to teach focused transesophageal echocardiography for out-of-hospital cardiac arrests to emergency physicians are rigorously outlined. These components based on a Kern model include problem identification and a general needs assessment, a targeted needs assessment, defining goals and objectives, choosing educational strategies, curricular implementation, and program evaluation. CONCLUSIONS: Use of a six-step Kern model as a template can facilitate the development and dissemination of a curriculum to teach emergency physicians successfully to employ focused transesophageal echocardiography in the treatment of cardiac arrests. In order to promote its widest dissemination, this model should be pursued in a “train-the-trainer” fashion. In so doing, appropriate education of emergency physicians and their use of transesophageal echocardiography to manage cardiac arrests likely can be rapid and impactful, especially among providers with training and experience in transthoracic echocardiography.

Using quality improvement approaches to increase emergency department provider engagement in research participant enrollment during COVID-19 and opioid overdose public health emergencies.

We utilized quality improvement (QI) approaches to increase emergency department (ED) provider engagement with research participant enrollment during the opioid crisis and coronavirus disease (COVID-19) pandemic. The context of this work is the Evaluating Microdosing in the Emergency Department (EMED) study, a randomized trial offering buprenorphine/naloxone to ED patients through randomization to standard or microdosing induction. Engaging providers is crucial for participant recruitment to our study. Anticipating challenges sustaining long-term engagement after a 63% decline in provider referrals four months into enrollments, we applied Plan-Do-Study-Act (PDSA) cycles to develop and implement an engagement strategy to increase and sustain provider engagement by 50% from baseline within 9months. Our engagement strategy was centered on Coffee Carts rounds: 5-min study-related educational presentations for providers on shift; and a secondary initiative, a Suboxone Champions program, to engage interested providers as study-related peer educators. We used provider referrals to our team as a proxy for study engagement and report the percent change in mean weekly referrals across two PDSA cycles relative to our established referral baseline. A QI approach afforded real-time review of interventions based on research and provider priorities, increasing engagement via mean weekly provider referrals by 14.5% and 49% across two PDSA cycles relative to baseline, respectively. Our Coffee Carts and Suboxone Champions program are efficient, low-barrier, educational initiatives to convey study-related information to providers. This work supported our efforts to maximally engage providers, minimize burden, and provide life-saving buprenorphine/naloxone to patients at risk of fatal overdose.

Assessment of Pregnancy Desires for Patients With Pregnancy of Unknown Location Seen in the Emergency Department [ID 2683447

INTRODUCTION: Desire for pregnancy should be centered in all discussions surrounding pregnancy management, including management of pregnancy of unknown location (PUL). Little is known about the evaluation of pregnancy desires for patients presenting to the emergency department (ED) found to have PUL. METHODS: We performed a retrospective cohort study of patients presenting to a tertiary-care ED with a positive pregnancy test and previously unconfirmed intrauterine pregnancy in the first trimester between January 2020 and December 2022. We excluded patients with chief complaints regarding known intrauterine pregnancy. The primary outcome was documentation of pregnancy desire by the ED provider. The secondary outcome was assessment of pregnancy desiredness by consulting gynecologic providers. Chi-squared and Fisher exact tests assessed for demographic variables. Institutional review board approval was obtained. RESULTS: Four hundred ninety-seven patients were included. Overall, only 105 (21.1%) of all patients and 12 (13.5%) patients with PUL were asked about pregnancy desiredness by the ED provider. While not statistically significant, patients with PUL had the lowest rate of being asked their pregnancy desires, compared to patients with confirmed intrauterine pregnancy (22.7%), ongoing miscarriage (28.1%), or ectopic/adnexal pathology (20.0%) (P=.15). Of those asked, 11 patients (10.5%) reported the pregnancy was undesired and 7 (6.7%) were unsure. There were no significant associations between asking pregnancy desires and age, race, ethnicity, parity, insurance, and language. For patients added to the beta book and followed by gynecology, 59.3% of patients were asked about their pregnancy desires. CONCLUSION: This study highlights gaps in early pregnancy evaluation and counseling, with only one in five patients asked their pregnancy desires. Patients with adnexal pathology and PUL had among the lowest rates of counseling, compared to those with ongoing miscarriage. This research suggests a missed opportunity for comprehensive pregnancy options counseling and management in the ED and the potential for improvement of care for patients with undesired PUL.

An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities. In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale. Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture. ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

Piloting racial bias training for hospital emergency department providers treating patients with opioid use disorder.

Racial disparities in opioid overdose have increased in recent years. Several studies have linked these disparities to health care providers' inequitable delivery of opioid use disorder (OUD) services. In response, health care policymakers and systems have designed new programs to improve equitable OUD care delivery. Racial bias training has been 1 commonly utilized program. Racial bias training educates providers about the existence of racial disparities in the treatment of people who use drugs and the role of implicit bias. Our study evaluates a pilot racial bias training delivered to 25 hospital emergency providers treating patients with OUDs in 2 hospitals in Detroit, Michigan. We conducted a 3-part survey, including a baseline assessment, post-training assessment, and a 2-month follow-up to evaluate the acceptability and feasibility of scaling the racial bias training to larger audiences. We also investigate preliminary data on changes in self-awareness of implicit bias, knowledge of training content, and equity in care delivery to patients with OUD. Using qualitative survey response data, we found that training participants were satisfied with the content and quality of the training and especially valued the small-group discussions, motivational interviewing, and historical context.

Cellular host response sepsis test for risk stratification of patients in the emergency department: A pooled analysis.

Sepsis is one of the most common, costly, and misdiagnosed conditions in U.S. emergency departments (EDs). ED providers often treat on nonspecific signs, subjective suspicion, or presumption of infection, resulting in over- and undertreatment. An increased understanding of host response has opened a new direction for sepsis diagnostics. The IntelliSep test is a U.S. Food and Drug Administration-cleared cellular host response diagnostic that could help distinguish sepsis in ED settings. Our objective was to evaluate the potential of the cellular host response test to expedite appropriate care for patients who present with signs of infection. We performed a pooled analysis of five adult (≥18 years) cohorts enrolled at seven geographically diverse U.S. sites in separate studies. Structured blinded adjudication was used to classify presence or absence of sepsis, and only patients with high confidence in the adjudicated label were included (n = 1002), defined as patients for whom there was consensus in the determination of sepsis per the Sepsis-3 and severe sepsis per the Sepsis-2 definitions between both the independent adjudication panel and the site-level physician. Among patients with signs or suspicion of infection, the test achieved similar or better performance compared to other indicators in identifying patients at high risk for sepsis (specificity > 83%) and significantly superior performance in identifying those at low risk (sensitivity > 92%; 0% sepsis-associated mortality). The test also stratified severity of illness, as shown by 30-day in-hospital mortality (p < 0.001), hospital length of stay (p < 0.01), and use of hospital resources (p < 0.001). Our data suggest that the cellular host response test provides clinically actionable results for patients at both high and low risk for sepsis and provides a rapid, objective means for risk stratification of patients with signs of infection. If integrated into standard of care, the test may help improve outcomes and reduce unnecessary antibiotic use.

Health-related social needs information in the emergency department: clinician and patient perspectives on availability and use

BackgroundPatient health-related social needs (HRSN) complicate care and drive poor outcomes in emergency department (ED) settings. This study sought to understand what HRSN information is available to ED physicians and staff, and how HRSN-related clinical actions may or may not align with patient expectations.MethodsWe conducted a qualitative study using in-depth semi-structured interviews guided by HRSN literature, the 5 Rights of Clinical Decision Support (CDS) framework, and the Contextual Information Model. We asked ED providers, ED staff, and ED patients from one health system in the mid-Western United Stated about HRSN information availability during an ED encounter, HRSN data collection, and HRSN data use. Interviews were recorded, transcribed, and analyzed using modified thematic approach.ResultsWe conducted 24 interviews (8 per group: ED providers, ED staff, and ED patients) from December 2022 to May 2023. We identified three themes: (1) Availability: ED providers and staff reported that HRSNs information is inconsistently available. The availability of HRSN data is influenced by patient willingness to disclose it during an encounter. (2) Collection: ED providers and staff preferred and predominantly utilized direct conversation with patients to collect HRSNs, despite other methods being available to them (e.g., chart review, screening questionnaires). Patients’ disclosure preferences were based on modality and team member. (3) Use: Patients wanted to be connected to relevant resources to address their HRSNs. Providers and staff altered clinical care to account for or accommodate HRSNs. System-level challenges (e.g., limited resources) limited provider and staff ability to address patients HRSNs.ConclusionsIn the ED, HRSNs information was inconsistently available, collected, or disclosed. Patients and ED providers and staff differed in their perspectives on how HSRNs should be collected and acted upon. Accounting for such difference in clinical and administrative decisions will be critical for patient acceptance and effective usage of HSRN information.

Development and Validation of a Natural Language Processing Model to Identify Low-Risk Pulmonary Embolism in Real Time to Facilitate Safe Outpatient Management

ObjectiveThis study aimed to (1) develop and validate a natural language processing (NLP) model to identify presence of PE based on real-time radiology reports and (2) identify low-risk PE patients based on previously validated risk stratification scores using variables extracted from the electronic health record (EHR) at the time of diagnosis. The combination of these approaches yielded an NLP-based clinical decision support tool that can identify patients presenting to the emergency department (ED) with low-risk PE as candidates for outpatient management. Research QuestionCan an NLP-based clinical decision support tool that uses real-time radiology reports and EHR data accurately identify patients presenting to the ED with low-risk PE? Study Designs and MethodsData were curated from all patients who received a PE-protocol computed tomography pulmonary angiogram (CTPA) imaging study in the ED of a three-hospital academic health system between June 1, 2018 and December 31, 2020 (n = 12,183). The “preliminary” radiology reports from these imaging studies made available to ED providers at the time of diagnosis were adjudicated as positive or negative for PE by the clinical team. The reports were then divided into development, internal validation, and temporal validation cohorts in order to train, test, and validate an NLP model that could identify presence of PE based on unstructured text. For risk stratification, patient and encounter-level data elements were curated from the EHR and used to compute a real-time simplified pulmonary embolism severity (sPESI) score at the time of diagnosis. Chart abstraction was performed on all low-risk PE patients admitted for inpatient management. ResultsWhen applied to the internal validation and temporal validation cohorts, the NLP model identified presence of PE from radiology reports with an AUROC of 0.99, sensitivity 0.86-0.87, and specificity 0.99. Across cohorts, 10.5% of PE-CTPA studies were positive for PE, of which 22.2% were classified as low-risk by sPESI score. Of all low-risk PE patients, 74.3% were admitted for inpatient management. InterpretationThis study demonstrates that an NLP-based model utilizing real-time radiology reports can accurately identify patients with PE. Further, this model, used in combination with a validated risk stratification score (sPESI), provides a clinical decision support tool that accurately identifies patients in the ED with low-risk PE as candidates for outpatient management.

Effect of the MISSION Act scribes trial on emergency department provider productivity and patient throughput time

BackgroundTo help improve access to care, section 507 of the VA MISSION Act of 2018 mandated a 2-year trial of medical scribes in the Veterans Health Administration (VHA). ObjectiveWe evaluate the impact of scribes on provider productivity and patient throughput time in VHA emergency departments (EDs). MethodsWe designed a clustered randomized trial using intent-to-treat difference-in-differences analysis. The intervention period was from June 30, 2020, to July 01, 2022. The trial included 6 intervention and 6 comparison ED clinics. Two volunteer ED providers were assigned two scribes each. Scribes assisted providers with documentation and visit-related activities. The outcomes were provider productivity and patient throughput time per clinic-pay period. ResultsRandomization to intervention resulted in decreased provider productivity and increased patient throughput time. In adjusted regression models, randomization to scribes was associated with a decrease of 8.4 visits per full-time equivalent (95% CI: 12.4, 4.3; p<0.001), and 0.5 patients per day per provider (95% CI: 0.8, 0.3; p<0.001). Intervention was associated with increases of 29.1 mins in length of stay (95% CI: 21.2, 36.9; p<0.001), 6.3 mins in door-to-doctor (95% CI: 2.9, 9.6; p<0.001), 19.5 mins in door-to-disposition (95% CI: 13.2, 25.9; p<0.001), and 13.7 mins in doctor-to-disposition (95% CI: 8.8, 18.6; p<0.001). ConclusionScribes were associated with decreased provider productivity and increased patient throughput time in VHA EDs. Although scribes may have contributed to improvements in other dimensions of quality, further examination of the ways in which scribes were used is advisable before widespread adoption in VHA EDs.

Older Adults Affected by Abuse-What about Their Mental Health and Social Participation? A Mixed Methods Study.

The purpose of the study was to describe what types of abuse of older adults the healthcare providers in hospital emergency departments are currently able to identify. The study aimed at producing new information about the identification of abuse to enable the development of staff skills in the identification of abuse and in optimal interventions. The study is the first on the topic from the perspective of hospital emergency staff in Finland. The 76 participants represent 5 hospitals. The results are based on a statistical analysis of quantitative questions and on an inductive content analysis of participant experiences of suspected abuse. The inductive content analysis revealed that older adults subjected to abuse have narrowed social networks and many of them surrender to loneliness. Based on the relevant literature, the study discusses how the formal and informal social participation and mental health of this group of people could be promoted. Given the current limited resources, it is proposed that the idea of social prescribing might be applied informally, with help of a volunteer link person. Any interventions should be based on the older adults' conceptions of what is meaningful to them.

Implementation and analysis of a multifaceted intervention for alcohol use disorder from a single academic urban emergency department.

From 2006 to 2014, alcohol-related visits to the emergency department (ED) increased by 76% in the United States, highlighting the need for improved ED-driven interventions addressing alcohol use disorder (AUD). Naltrexone is an FDA-approved medication for AUD shown to decrease craving and self-administration of alcohol. While oral naltrexone and extended-release naltrexone have been long utilized in primary care and inpatient hospital settings, the use of naltrexone in the ED is limited. This study implemented and analyzed a multifaceted intervention regarding ED naltrexone prescribing at a large safety net, academic, urban hospital. A baseline assessment of preintervention conditions and perspectives on naltrexone prescribing was conducted through a chart review and standardized interviews with ED providers, respectively. The interview results guided design of interventions that addressed identified barriers. These included provider education, prescribing aids, and zero-cost naltrexone tablets supplied by the ED pharmacy to patients upon discharge. Between September 1, 2019, and August 31, 2020, of 753 unique patients who had a primary diagnosis or chief complaint containing the word "alcohol," only five (0.66%) were prescribed naltrexone. ED providers identified lack of training regarding naltrexone, lack of a prescribing protocol, and limited patient and provider education materials as barriers to prescribing naltrexone. Following the intervention, among 278 eligible patients, 11 oral naltrexone prescriptions were written (3.96%) between April 13, 2021, and August 1, 2021. This represents a sixfold increase over the preintervention period. An intervention to increase ED oral naltrexone prescriptions for AUD was successfully implemented, addressing lack of provider education, lack of prescribing resources, and patient barriers to accessing prescribed medications. Longer-term follow-up is needed to assess the efficacy and sustainability of these interventions. Nevertheless, ED clinicians are well positioned to initiate naltrexone prescriptions for patients presenting with AUD.

The Implementation of a Clinical Pathway to Improve Child Abuse Screening in Young Children With Fractures: A Quality Improvement Analysis

The American Academy of Pediatrics recommends screening children under 2 years of age with a concerning fracture for physical abuse with a skeletal survey (SS). Nationally, 30% to 77% of children are not screened appropriately in emergency department settings. After implementation of an electronic clinical pathway for pediatric emergency department providers, guideline adherence improved from 61% to 81%. Among infants, SS performance increased from 79% to 81%. More non-White children received an SS, indicating potential implicit bias in screening practices. The results support clinical pathways to improve guideline adherence while promoting further examination of providers’ determination of screening needs.

Abstract NS2: An Expedited Transfer Process Improves Door In Door Out Times

Background: Rapid reperfusion with mechanical thrombectomy for ischemic stroke secondary to large vessel occlusion leads to significant reduction in morbidity and mortality. DIDO time is an important metric for stroke centers without on-site mechanical thrombectomy. Delays in treatment can occur when patients present at a Primary Stroke Center (PSC) then require transfer to the CSC for MT. Our system Comprehensive Stroke Center (CSC) receives patients from 2 of our system’s PSCs. In order to expedite care an expedited transfer protocol was implemented. Purpose: The goal of this work is to decrease the time at the PSC, known as door-in-door-out (DIDO), and decrease overall time from patient presentation to treatment with thrombectomy. Methods: Patients are screened at triage by a PSC emergency department provider for the following: aphasia, gaze preference, or neglect with unilateral weakness within 24 hours of last known normal. If these criteria are present, the emergency department provider contacts the CSC transfer center to initiate the expedited transfer process, which begins mobilizing resources to the PSC while clinical work-up continues. This expedited early transfer process was implemented in January 2021. Transfers for MT during the 12-month period before and after the implementation of the expedited transfer process were analyzed. Results: A sustained reduction in overall DIDO was observed during the time period following implementation of the expedited transfer process (Fig 1) Mean DIDO was lower when the transfer call was placed before CT vs after CT (81 min vs. 132 min respectively) (p=.0031). Conclusions: Use of the Expedited Transfer Process allows transfer resources to begin moving to the patient with a suspected LVO in parallel with ongoing evaluation, resulting in faster DIDO times leading to faster treatment aimed at reducing stroke morbidity and mortality. Further analysis of the effect of the expedited transfer process on DIDO times is planned.

Abstract TP54: Ready to Ride

Background: For stroke patients initially presenting to a primary stroke center with large vessel occlusions (LVO), treatment involves evaluation and subsequent transfer for thrombectomy. Our institution has utilized many of the AHA best practice strategies for improving door-in-door-out (DIDO), though targeting efficiency of the hand-off to the transporting team was not previously targeted. Purpose: This process sought to streamline hand-offs to the transporting team to improve overall DIDO times at our primary stroke center, specifically through decreasing the average transport team arrival to patient departure time. Methods: We identified multiple opportunities for intervention: improved documentation of Emergency Department departure time, standardized communication with transport team, and need for consistent path to helipad. A standard method of communicating transport team estimated arrival was established to ensure readiness of emergency department staff and patient for transport to helipad. A structured report including the required paperwork was created for all transfers between the emergency department providers and transport team. Lastly, a consistent path to the helipad itself was identified. A Mann Whitney Test was used to compare the means of door in to transport departure and transport arrival to transport departure. Transport departure was used as the standard for door out. Results: Mean for door to transport departure pre intervention was 126.47 (STD of 33.13). Post-intervention was 126. 43 with STD of 56.62. This was not significant (p=0.76). Mean for transport arrival to transport departure prior to intervention was 26.72 minutes (STD of 8.44) and post intervention was 19.86 (STD of 16.65). This was significant (p=0.01). Conclusions: Standardizing hand-offs and improving transport efficiency and communication are feasible interventions in overall efforts to improve care delivery and efficiency. Early data suggests these interventions decrease time between transport arrival and door out. Further work is necessary to assess impact on DIDO.

Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models.

The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.

(O-F6) A Mixed-methods Study of Barriers and Facilitators to Point-of-care Ultrasound Implementation for Emergency Department Providers at the Durham Veterans Affairs Healthcare System

(O-F6) A Mixed-methods Study of Barriers and Facilitators to Point-of-care Ultrasound Implementation for Emergency Department Providers at the Durham Veterans Affairs Healthcare System

Perspectives of emergency department physicians and nurses on reasons for preventable emergency department visits by patients with cancer

BackgroundPatients with cancer frequently visit the emergency department (ED) for medical care, yet approximately half of ED visits for patients with cancer are thought to be preventable. Preventable ED visits are associated with increased healthcare costs and poor patient experiences and outcomes. The voices of ED providers who work with patients with cancer in their everyday practices have not been solicited as it pertains to preventable visits. ObjectivesThe purpose of this study is to describe the perspectives of ED physicians and nurses on reasons for preventable ED visits by patients with cancer. MethodsA qualitative descriptive design guided the study. We conducted 23 semi-structured interviews with ED physicians and nurses to query them about their perspectives on the reasons for preventable ED visits by patients with cancer. Content analysis was conducted to list and describe the reasons they discussed. ResultsParticipants identified five “medical” and five “non-medical” causes of preventable ED visits. Medical reasons included uncontrolled cancer pain, gastrointestinal symptoms, anemia, fever, and on-going undiagnosed signs and symptoms. Non-medical reasons include patient hesitancy to contact primary care providers, lack of availability or responsiveness of primary providers, lack of access, lack of care coordination, and fears about diagnosis and treatment. ConclusionThe voices of ED providers should be included in discussions about the problem of preventable ED visits by patients with cancer. The reasons supplied by the participants suggest that solutions to the problem will need to occur at the patient, provider, system, and societal levels.