Quality Of Care In Emergency Department Research Articles

Machine learning models for predicting unscheduled return visits to an emergency department: a scoping review

BackgroundUnscheduled return visits (URVs) to emergency departments (EDs) are used to assess the quality of care in EDs. Machine learning (ML) models can incorporate a wide range of complex predictors to identify high-risk patients and reduce errors to save time and cost. However, the accuracy and practicality of such models are questionable. This review compares the predictive power of multiple ML models and examines the effects of multiple research factors on these models’ performance in predicting URVs to EDs.MethodsWe conducted the present scoping review by searching eight databases for data from 2010 to 2023. The criteria focused on eligible articles that used ML to predict ED return visits. The primary outcome was the predictive performances of the ML models, and results were analyzed on the basis of intervals of return visits, patient population, and research scale.ResultsA total of 582 articles were identified through the database search, with 14 articles selected for detailed analysis. Logistic regression was the most widely used method; however, eXtreme Gradient Boosting generally exhibited superior performance. Variations in visit interval, target group, and research scale did not significantly affect the predictive power of the models.ConclusionThis is the first study to summarize the use of ML for predicting URVs in ED patients. The development of practical ML prediction models for ED URVs is feasible, but improving the accuracy of predicting ED URVs to beyond 0.75 remains a challenge. Including multiple data sources and dimensions is key for enabling ML models to achieve high accuracy; however, such inclusion could be challenging within a limited timeframe. The application of ML models for predicting ED URVs may improve patient safety and reduce medical costs by decreasing the frequency of URVs. Further research is necessary to explore the real-world efficacy of ML models.

Referral of community-dwelling older adults from eight emergency departments in Canada: A secondary analysis of cross-sectional data from the interRAI multinational emergency department (ED) cohort study

Background: Emergency Department (ED) overcrowding, unnecessary hospitalization, and alternate level of care has been identified as a major issue in Canada and around the world. This problem especially impacts older adult populations, who are at elevated risk of functional decline and adverse events in hospital-centric systems. This study uses data from the interRAI ED Contact Assessment (ED-CA)[1], a comprehensive geriatric assessment used in the ED, to improve our understanding of ED systems of referral to community resources.
 Target Audience: ED staff in clinical and leadership positions interested in better understanding community referral processes to improve care for community-dwelling older adults.
 Methods: This study is a secondary analysis of cross-sectional Canadian data from a cohort study of elderly ED patients. The cohort of community-dwelling patients aged 65 and older presented to the ED between April 2017 and July 2018. They were screened and recruited in 10 EDs across Ontario, Quebec, and Newfoundland. The data were analyzed using frequency and logistic regression analyses, then the results were interpreted in collaboration with two geriatricians and one physiotherapist.
 What was done: This study explored referral patterns and identified predictors of referral from the ED to five different community health services (occupational therapy, physiotherapy, home care, social work, and/or specialized geriatric services) for supporting community-dwelling older adults. 
 Results: We found that the sample (n=1055) was frail, with high needs and a high risk of ED revisit and institutionalization. Over half of the sample was referred to home care, occupational therapy, and/or physiotherapy, while only 16% were referred to specialized geriatric services. Most patients received multiple referrals from the ED. Province was the most impactful predictor for referral to occupational therapy or physiotherapy (OR for Ontario vs. Quebec=62.12, 95% CI [19.04, 202.70]) and home care (OR for Ontario vs. Quebec=12.09, 95% CI [5.81, 25.17]), while having an unstable condition was the most impactful predictor for social work referral (OR=5.51, 95% CI [3.78, 8.02]) and weight loss was the most impactful predictor for specialized geriatric service referral (OR=8.13, 95% CI [5.49, 12.04]). Other notable predictors included having overwhelmed family members, self-rated health, and having had a fall in the last 90 days.
 Key Learnings: Occupational therapy, physiotherapy, home care, social work, and specialized geriatric services are distinct services, specialized in addressing a specific set of care needs. We learned that specialized geriatric services are underutilized and may be poorly understood.
 Next Steps: To improve the quality of ED care, we have provided recommendations for restructuring care processes to promote shifts in clinical culture, evidence-informed decision-making, and proactive referral to community health services.

Impact of interhospital transfer on emergency department timeliness of care and in-hospital outcomes of adult non-trauma patients

BackgroundPatients who present to the emergency department (ED) from interhospital transfer (IHT) and non-IHT are known to have differences in various clinical outcomes including mortality. The ED timeliness of care is an effective indicator of the quality of ED care and operational efficiency. The impact of IHT on ED timeliness of care remains unclear. We evaluated the association between IHT and ED timeliness of care or in-hospital outcomes in adult non-trauma patients. MethodsData of consecutive hospital admission of adult non-trauma patients who visited the ED of a medical center from January 2018 to Jun 2020 were retrospectively analyzed. The patients were divided into IHT and non-IHT cohorts. Various data were recorded. The ED length of stay (LOS) was measured as the outcome of ED timeliness of care, while hospital LOS and in-hospital death were measured as the in-hospital outcomes. Multiple regression analyses were performed using unmatched and propensity-matched cohorts. In the later analyses, both groups were propensity matched for sex, age, and other covariates that showed significant differences between two groups to achieve a 1:4 balanced cohort. ResultsData on 1856 IHT patients and 16295 non-IHT patients were analyzed. IHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death compared with non-IHT in unmatched and propensity-matched analyses. The shorter ED LOS was due to the slightly longer interval of arrival to ED physicians (∼1 min) and considerably shorter intervals of ED physicians to decision (∼120 min) and decision to departure (∼105 min). Risk stratification revealed that IHT was associated with a shorter ED LOS in patients with all levels (1–5) of Taiwan Triage and Acuity Scale (TTAS) and associated with longer hospital LOS and higher odds of in-hospital death in patients with TTAS level ≥3. ConclusionsIHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death in adult non-trauma patients compared with non-IHT. The expedited ED timeliness of care in the IHT cohort was due to considerably shorter intervals of both ED physicians to decision and decision to disposition.

A program for volunteers accompanying older patients with cognitive dysfunction to improve the quality of emergency department care: A pilot study

Admission to an emergency department (ED) is challenging for older patients with cognitive dysfunction (PWCD). Targeted patient-oriented approaches to improve the care for PWCD are needed. The aim of this pilot study was to design and evaluate a program for volunteers to support PWCD in the ED. Volunteers (N = 9) first received a training and during the following six months (N = 90 shifts), they accompanied PWCD (N = 112) during their stay. Results showed that the training increased volunteers’ knowledge and expertise, but not shift-related self-efficacy. The most frequent strategies applied were conversations, holding hands and touching, and providing food and drinks. After six months, volunteers reported a great sense of meaningfulness and felt that they were highly appreciated by the patients. ED nurses’ sceptical attitudes towards the program decreased. The program is beneficial for PWCD, appears to be meaningful for volunteers and is appreciated by ED nurses.

Efficiency measures of emergency departments: an Italian systematic literature review

Life expectancy globally increased in the last decades: the number of people aged 65 or older is consequently projected to grow, and healthcare demand will increase as well. In the...

Analysis of Factors Associated With Length of Stay of Opioid-Related Emergency Department Visits.

Introduction and Objective: Emergency department (ED) length of stay (LOS) is an important indicator of the quality of care in ED and is associated with patients’ outcomes and healthcare costs. However, there is limited data on how the patient characteristics affect the ED LOS of opioid-related visits. This study aims to identify and quantify the effect of patient-related characteristics on LOS of opioid-related ED visits.Methods: This is a retrospective analysis of electronic health records (EHR) of patients with diagnoses of opioid abuse. The study included patients with a diagnosis of opioid abuse who visited the ED at Christiana Care Hospital from January 1, 2017, to December 31, 2018 (N=5,661). The opioid-related visits were identified using ICD-10 diagnosis codes. We used accelerated failure time (AFT) models, a time-to-event analysis approach to evaluate the relationships of different patient characteristics with ED LOS.Results: The mean age of the study population was 39 years. The study population had 40% female, 20% Black/African American, and 5% Hispanic or Latino. The prevalence of co-use of cocaine and co-use of alcohol was 11%, and 9%, respectively. Also, 58% had mental health comorbidity, and 1% were homeless. The distribution of ED LOS was right-skewed with a median of 4.3 (IQR: 2.6, 6.8). Co-use of alcohol (time ratio, TR: 1.31, CI: 1.23-1.40), co-use of cocaine (TR: 1.18, CI: 1.11-1.25), the presence of mental health comorbidity (TR: 1.05, CI 1.01-1.09), and homelessness (TR: 1.57, CI: 1.32-1.86) were associated with increased ED LOS.Conclusions: Co-use of alcohol, co-use of cocaine, homelessness, and mental health comorbidity are associated with the longer LOS of opioid-related ED visits.

A novel reflective practice intervention improves quality of care in the emergency department

IntroductionMost interventions to improve clinical outcomes in the emergency department (ED) are based on structural changes. This study embraced a different strategy and examined the impact of a reflective practice intervention (RPI) on ED quality of care. MethodsA pre-post-intervention quasi-experimental nested design was conducted between January 2017 and June 2018 in an Israeli public tertiary academic ED. Nighty-six ED teams (triage and staff nurses and a physician) were included pre and post RPI. Data were collected pre and post RPI at patient–triage nurse encounters using triage-accuracy questionnaires. Time to decision, length-of-stay, and hospitalization and mortality rates were retrieved from the medical charts of 1920 patients (20 per team). ResultsAccurate triage was significantly higher post than pre intervention (4.84 ± 1.45 vs. 3.87 ± 1.48; range 1–7; p < .001), whereas time to decision (253.30 ± 246.75 vs. 304.64 ± 249.14 min), hospitalization rates (n = 291, 30.3% vs. n = 374, 39.0%; p < .001), and hospital length-of-stay (5.73 ± 6.72 vs. 6.69 ± 6.20; p = .04) significantly decreased. ConclusionsBy adapting organizational reflective practice principles to the ED dynamic environment, the RPI was associated with a significant improvement in ED quality-of-care measures.

10-Year Trends of Emergency Department Visits, Wait Time, and Length of Stay among Adults with Mental Health and Substance use Disorders in the United States.

This study examined if there was a change in the number of Emergency Department (ED) visits, wait time, and length of stay among adults with mental health and substance use disorders (MHSUD) in the United States from 2006 to 2015. From the National Hospital Ambulatory Medical Care Survey, a total of 17,488 ED visits by adults with MHSUD were identified. Linear regression and negative binomial regression analyses were conducted to assess statistically significant changes in trends of ED visits, wait time, and length of stay. Results indicated that ED visits by adults with MHSUD increased by 30.6% from 2006 to 2015. Wait time of ED visits by adults with MHSUD decreased for the same time period; however, length of stay did not change. Also, there were some differences in trends of wait time and length of stay by diagnosis. Specifically, wait time of ED visits by adults with psychotic disorders did not decrease. Length of stay of ED visits by adults with anxiety disorders statistically significantly increased from 2006 to 2015. More effort is needed to improve the quality of ED care for adults with MHSUD. In such an effort, diagnoses should be taken into consideration.

Risk factors of admission in 72-h return visits to emergency department.

Objective:Return visit to emergency department (ED) is a common phenomenon and has been a clinical indicator of quality of care in ED. Most of previous articles focused on the characteristics of the patients returning within 72 h after ED discharge, while those on subsequent admission are numbered. This study's purpose is to identify risk factors for admission among 72-h return visit in the ED adult population.Materials and Methods:This retrospective cohort study was conducted at a medical center in Eastern Taiwan. The study period was from January 1, 2013, to December 31, 2013. We excluded patients who left against medical advice or without being seen, who was admitted or transferred at the index ED visit, whose medical records were incomplete, and whose age was below 18 years old. Significant variables were selected based on univariate analysis and later entered into multivariate logistic regression analysis to identify risk factors for 72-h return admission.Results:We identified 1575 eligible visits, and there were 1,119 visits entering into the final analysis. Male gender (odds ratio [OR] = 1.44), ambulance-transport at return visit (OR = 3.68), senior staff (OR = 1.52), work-up (OR = 3.03), and longer length of stay (LOS) were associated with higher risks of admission among ED 72-h return visits. Age, comorbidity, mode of transport at index visit, consultation, triage, type of illness, outpatient department visit between ED visits, and interval between index and return visits were not significantly associated with return admission.Conclusion:Gender, mode of transportation, staff experience, check-up, and LOS are associated with ED return admission.

Emergency Department Quality of Care for Sickle Cell Disease in Ontario, Canada: A Population-Based Matched Cohort Study

Background: Acute vaso-occlusive crisis (VOC) in sickle cell disease (SCD) frequently leads patients to seek emergency department (ED) care. Whether or not health inequities exist, and their exact nature, is poorly understood in ED visits for SCD VOC within a universal publicly funded healthcare system. In this study, we aimed to address this knowledge gap by characterizing the landscape of ED care burden and quality indicators for SCD VOC management in the province of Ontario, Canada. Methods: We used population-level health administrative data to identify patients with SCD in Ontario who presented to the ED with SCD VOC (ICD-10-CA code D57.0) from 2006 to 2018. We evaluated quality of care indicators in the ED for this population and compared these with a general population group matched by age, sex, neighbourhood income quintile, geography (forward sortation area) and date of ED visit (-15 to +15 days per visit) (35,370 ED visits; 27,195 patients). Results: We identified 1,811 patients who presented to the ED with SCD VOC for a total of 13,123 ED visits over the study period. Of ED presentations, 40% were pediatric (&amp;lt; 18 years), 47% were male and 99% lived in urban settings. Compared to ED visits for the matched group, ED visits for SCD VOC had a significantly higher proportion of high acuity triage scores (CTAS 1 or 2) (74% vs 18%; p &amp;lt; 0.001), shorter time to initial physician assessment (76 ± 82 vs 90 ± 86 minutes; mean ± SD, p &amp;lt; 0.001), longer period of ED assessment and observation (432 ± 261 vs 212 ± 179 minutes; p &amp;lt; 0.001), increased likelihood of hospital admission (62% vs 5%; p &amp;lt; 0.001), longer duration of inpatient stay (5.2 ± 6.7 vs 4.0 ± 8.1 days; p &amp;lt; 0.001), and higher rates of repeat ED visits within 30 days of ED discharge (0.57 ± 1.44 vs 0.26 ± 0.79 visits; p &amp;lt; 0.001). We found specific socio-demographic variables associated with a poorer quality of care in ED visits for SCD VOC, including patients who were adults, male, from a low-income neighbourhood, having a greater number of dependents, a higher neighbourhood level of material deprivation, from an ethnically-concentrated neighbourhood, and those who lived in a residentially unstable region. Bivariate analyses for clinically meaningful outcomes (defined as ED disposition, repeat ED visit within 30 days, length of hospital admission stay, and being among the highest user bracket of ED care) further revealed significant socio-demographic associations that validated the clinical relevance of these determinants underlying ED metric disparities found within the SCD cohort (Table 1). In subgroup comparisons, we observed a significant difference in triage acuity scoring for adults compared with children with SCD VOC, with a 25% lower rate of high acuity triage score (CTAS 1 or 2) (66% vs 86%). We also found that despite a majority of adults with SCD VOC receiving these scores compared to those in the matched group (66% vs 18%), their mean times to initial physician assessment were not significantly different (90 ± 94 vs 91 ± 89 minutes), reflecting an average SCD VOC wait time longer than the clinical practice guideline recommendation of first dose analgesic within the first 60 minutes of ED arrival. Furthermore, we identified a negative correlation between poor ED metrics and patients with SCD who were highly dependent on ED care (defined as 4-9 or ≥ 10 ED visits for SCD VOC per year) at levels significantly above the matched comparative baseline. Conclusions: Indicators of ED care for SCD largely reflect the clinical acuity and severity of VOC presentations in Ontario, Canada. However, significant disparities in the quality of care received and in clinical outcomes for specific subgroups of patients with SCD, including those most vulnerable within this patient population, raises concern from a health equity perspective.By leveraging this landscape of SCD ED care, future policy, clinical and research efforts must work to understand, address and close these gaps in order to achieve best and equitable care for all. Disclosures No relevant conflicts of interest to declare.

Exploring patients and family members' experiences of care in the emergency department.

Patient experience and satisfaction are often used to evaluate the quality of care provided in emergency departments (EDs). Several studies have evaluated the experiences of patients and their family members in EDs internationally, but few studies have investigated the experiences of those attending EDs in Iran. To investigate patients and family members' experiences of care in one ED in Iran. Semi-structured interviews were conducted with 17 patients and ten family members in one ED in Tehran, Iran. A qualitative content analysis approach was used to analyse the data. Three themes emerged from the data: quality of nursing care; satisfaction with medical care and waiting times; and adequate diagnostic testing and equipment. Participants reported several issues in relation to the care provided in the ED, including a lack of attention from nursing staff, long waiting times, delays in symptom management, and family members' involvement in care to compensate for high staff workload and overcrowding. The findings of this study demonstrate that the most important determinants of patients and family members' experiences in EDs are the quality of nursing and medical care, the length of waiting times, and adequate diagnostic testing and equipment. While it may be beneficial to involve family members in patient care, regular communication with them is essential to explain challenging situations that may affect the quality of ED care, such as low staff levels.

Assessing 30-day avoidable readmission rates: Is it an appropriate tool to manage emergency department quality of care?

Objective: Quality indicators, based on administrative data, are being increasingly used to assess avoidable hospital readmission rates. Their potential to identify areas for improvement at low cost is attractive, but their performance in emergency departments (EDs) has been criticised.Methods: Hospital readmissions were categorised as potentially avoidable or non-avoidable, by a computerised algorithm (SQLape®, version 2016 - Striving for Quality Level and analysing of patient expenditures). Half-yearly rates were reported between July 2015 and June 2016. Two senior physicians conducted a medical record review on 100 randomly selected cases from an ED, flagged as potentially avoidable readmissions (PAR). Results were then discussed with the algorithm’s designer.Results: The algorithm screened 2,182 eligible emergency visits - 105 cases (4.8%), were deemed potentially avoidable by the algorithm. Among 100 randomly selected cases, nine exclusions were due to coding issues and four due to false positives. Overall (N = 87), 20/87 (23%) of readmissions were directly related to sole emergency care, 31/87 (36%) related to healthcare providers other than the ED, and 23/87 (26%) were of mixed provision, while 13/87 (15%) were attributed to the course of the disease.Conclusions: The study confirms the need for a better understanding of the algorithm’s measurement and of its reported results. Careful interpretation is required before a sound conclusion can be made. Indeed, it is apparent that the 30-day PAR quality indicator rate reflects a wider parameter of care than hospitals alone, who understandably tend to concentrate on their own, direct liability of care. In particular the 30-day PAR quality indicator is not well-suited to evaluate ED performance.

End-of-life management protocol offered within emergency room (EMPOWER): study protocol for a multicentre study

BackgroundPatients at their end-of-life (EOL) phase frequently visit the emergency department (ED) due to their symptoms, yet the environment and physicians in ED are not traditionally equipped or trained to...

Early short-term prediction of emergency department length of stay using natural language processing for low-acuity outpatients

BackgroundLow-acuity outpatients constitute the majority of emergency department (ED) patients, and these patients often experience an unpredictable length of stay (LOS). Effective LOS prediction might improve the quality of ED care and reduce ED crowding. ObjectiveThe objective of this study was to explore the potential of natural language processing (NLP) of the first ED physicians' clinical notes and to evaluate NLP-based short-term prediction models based on mixed-type clinical data. MethodsA retrospective study was conducted at an ED of a tertiary teaching hospital in Taiwan from January 2017 to June 2017. In total, 12,962 low-acuity outpatients were enrolled. Using structured data (e.g., demographic variables and vital signs) and different sections of the first SOAP notes as predictors, we developed six NLP-based prediction models (i.e., term frequency-inverse document frequency (TF-IDF) and truncated singular value decomposition (SVD)) to predict LOS. The metric for model evaluation is the mean squared error (MSE). ResultsOf the six NLP-based models, the model using structured data and all the sections of the first SOAP notes processed by the TF-IDF and truncated SVD method performed the best, with an MSE of 3.00 [95% CI: 2.94–3.06]. In addition, ten important topics extracted by the TF-IDF and truncated SVD method had significant effects on the LOS (p < 0.001). ConclusionNLP-based models can be used as an early short-term prediction of LOS and have the potential for mixed-type clinical data analysis. The proposed models would likely aid ED physicians' decision-making processes and improve ED quality of care.

Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research

BackgroundOlder adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit.MethodsThis is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital’s geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates.DiscussionA protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting.Trial registrationClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019

Patient classification based on volume and case-mix in the emergency department and their association with performance.

Predicting daily patient volume is necessary for emergency department (ED) strategic and operational decisions, such as resource planning and workforce scheduling. For these purposes, forecast accuracy requires understanding the heterogeneity among patients with respect to their characteristics and reasons for visits. To capture the heterogeneity among ED patients (case-mix), we present a patient coding and classification scheme (PCCS) based on patient demographics and diagnostic information. The proposed PCCS allows us to mathematically formalize the arrival patterns of the patient population as well as each class of patients. We can then examine the volume and case-mix of patients presenting to an ED and investigate their relationship to the ED's quality and time-based performance metrics. We use data from five hospitals in February, July and November for the years of 2007, 2012, and 2017 in the city of Calgary, Alberta, Canada. We find meaningful arrival time patterns of the patient population as well as classes of patients in EDs. The regression results suggest that patient volume is the main predictor of time-based ED performance measures. Case-mix is, however, the key predictor of quality of care in EDs. We conclude that considering both patient volume and the mix of patients are necessary for more accurate strategic and operational planning in EDs.

Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial.

Background and Purpose- We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods- A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke <48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (<4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results- Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions- This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration- URL: http://www.anzctr.org.au. Unique identifier: ACTRN12614000939695.

Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan

BackgroundThere is little data describing pediatric emergencies in resource-poor countries, such as Pakistan. We studied the demographics, management, and outcomes of patients presenting to the highest-volume, public, pediatric emergency department (ED) in Karachi, Pakistan.MethodsIn this prospective, observational study, we approached all patients presenting to the 50-bed ED during 28 12-h study periods over four consecutive weeks (July 2013). Participants’ chief complaints and medical care were documented. Patients were followed-up at 48-h and 14-days via telephone.ResultsOf 3115 participants, 1846 were triaged to the outpatient department and 1269 to the ED. Patients triaged to the ED had a median age of 2.0 years (IQR 0.5–4.0); 30% were neonates (< 28 days). Top chief complaints were fever (45.5%), diarrhea/vomiting (32.3%), respiratory (23.1%), abdominal (7.5%), and otolaryngological problems (5.8%). Temperature, pulse and respiratory rate, and blood glucose were documented for 66, 42, and 1.5% of patients, respectively. Interventions included medications (92%), IV fluids (83%), oxygen (35%), and advanced airway management (5%). Forty-five percent of patients were admitted; 11 % left against medical advice. Outcome data was available at time of ED disposition, 48-h, and 14 days for 83, 62, and 54% of patients, respectively. Of participants followed-up, 4.3% died in the ED, 11.5% within 48 h, and 19.6% within 14 days.ConclusionsThis first epidemiological study at Pakistan’s largest pediatric ED reveals dramatically high mortality, particularly among neonates. Future research in developing countries should focus on characterizing reasons for high mortality through pre-ED arrival tracking, ED care quality assessment, and post-ED follow-up.

P096: Real-time 72 hour readmission alert

Introduction: Hospital admission within 72 hours of emergency discharge is a widely accepted measure of emergency department quality of care. Patients returning for unplanned admission may reveal opportunities for improved emergency or followup care. Calgary emergency physicians, however, are rarely notified of these readmissions. Aggregate site measures provide a high level view of readmissions for managers, but dont allow for timely, individual reflection on practice and learning opportunities. These aggregations may also not correctly account for variation in planned readmissions and other workflow nuances. There was a process in place at one facility to compile and communicate readmission details to each physician, but it was manual, provided limited visit detail, and was done weeks or months following discharge. Methods: A new, realtime 72 hour readmission notification recently implemented within the Calgary Zone provides direct and automated email alerts to all emergency physicians and residents involved in the care of a patient that has been readmitted. This alert is sent within hours of a readmission occurring and contains meaningful visit detail (discharge diagnosis, readmit diagnosis, patient name, etc) to help support practice reflection. An average of 15 alerts per day are generated and have been sent since implementation in April, 2017. Although an old technology, the use of email is a central component of the solution because it allows physicians to receive notifications at home and outside the hospital network where they routinely perform administrative tasks. A secondary notification is sent to personal email accounts (Gmail, Hotmail, etc) to indicate an unplanned admission has occurred, but without visit detail or identifiable information. It also allowed implementation with no new hardware or software cost. Results: A simple thumbs up/down rating system is used to adjust the sensitivity of the alert over time. More than 66% of those providing feedback have indicated the alert is helpful for practice reflection (i.e., thumbs up). And of those that indicated it was not helpful, comments were often entered indicating satisfaction with the alert generally, or suggestions for improvement. For example, consulted admitting physicians are often responsible for discharge decisions and should be added as recipients of the alert. Conclusion: Many physicians have indicated appreciation in knowing about return patients, and that they will reflect on their care, further review the chart, or contact the admitting physician for further discussion. Most are accepting of some ‘expected’ or ‘false positive’ alerts that aren’t helpful for practice reflection. Further tuning and expansion of the alert to specialist and consult services is needed to ensure all physicians involved in a discharge decision are adequately notified.

LO77: Predictors of adverse self-reported 10-day outcomes in emergency department patients with acute ureteral colic

Introduction: Our objective is to investigate predictors of adverse patient reported outcomes during the 10 days after an index emergency department (ED) encounter for ureteral colic. Methods: This prospective two-city patient experience survey enrolled ED patients with confirmed 2-10 mm ureteric stones. Researchers telephoned consenting patients 10 days post-ED visit and assessed quality of life (QoL) using survey items from the VR-12 Health Outcome Survey. We used five survey items and three other variables to derive a composite measure of patient adverse experience (AE). The association between patient characteristics, symptoms and perceptions of care with outcome was determined using multiple logistic regression. Results: Of 224 patients studied (68% male, mean age 52 years) 154 (68.8%) indicated that one or more of the following AEs occurred during their 10day followup interval: 103 (46%) reported that the impact of pain on their life was &gt;4/10; 87 (39%) described poor or fair health status; 83 (37%) required &gt;7days for return of normal function; 66 (27.7%) had &gt;2 severe pain episodes per day; 62 (27.7%) required ED revisit or hospitalization; 47 (21%) found usual activities were limited most or all the time; 45 (20%) required &gt;2 opioid doses/day; and 24 (10.7%) lost &gt;7 work days. A composite measure derived from 3 survey items (days to normal, pain impact, health status) captured 92% of patients with adverse experiences. On multivariable logistic regression modeling, the strongest predictors of adverse (composite) outcome were male sex (adjusted OR=0.44; CI, 0.22-0.85), (excellent) quality of physician answers (OR=0.40; CI,0.2-0.77), proximal or mid-ureteric stone (OR=1.9; CI, 1.1-3.5), arrival pain severity (OR=1.18 per unit increase; CI,1.01-1.4), and perceived physician skill (OR=0.81; CI, 0.65-1.0). Patient age, stone size, pain duration, nausea, discharge pain and perceived ED care quality were not independent predictors of 10-day adverse patient experience in multivariate models. Conclusion: Patient sex, quality of physician communication, patient sex, arrival pain severity, and proximal stone location are highly associated with 10-day patient reported AE.