Reason For Emergency Department Visits Research Articles

Which adults aged 65 and older are at low-risk for cervical spine injuries after low-level falls?

The population is aging and falls are a common reason for emergency department visits. Appropriate imaging in this population is important. The objectives of this study were to estimate the prevalence of cervical spine injury and identify factors associated with cervical spine injuries in adults ≥ 65years after low-level falls. This was a pre-specified sub-study of a prospective observational cohort study of intracranial bleeding in emergency patients ≥ 65years presenting after low-level falls. The primary outcome was cervical spine injury. The risk factors of interest were Glasgow coma scale (GCS) < 15, head injury, neck pain, age, and frailty defined as Clinical Frailty Scale ≥ 5. Multivariable logistic regression was used to measure the strength of association between risk factors and cervical spine injury. A descriptive analysis of absence of significant risk factors was performed to determine patients who may not require imaging. There were 4308 adults ≥ 65 who sustained low-level falls with mean age of 82.0 (standard deviation ± 8.8) years and 1538 (35.7%) were male; 23 [0.5% (95% confidence interval (CI) 0.3-0.8%)] were diagnosed with cervical spine injuries. The adjusted odds ratios and 95% CIs were 1.3 (0.5-3.2) for GCS < 15, 5.3 (1.7-26.7) for head injury, 13.0 (5.7-31.2) for new neck pain, 1.4 (1.0-1.8) for 5-year increase in age, and 1.1 (0.4-2.9) for frailty. Head injury or neck pain identified all 23 cervical spine injuries. Management was a rigid collar in 19/23 (82.6%) patients and none had surgery. In emergency patients ≥ 65years presenting after a low-level fall, head injury, neck pain, and older age were associated with the diagnosis of cervical spine injury. There were no cervical spine injuries in those without head injury or neck pain. Patients with no head injury or neck pain may not require cervical spine imaging.

Aggressive Rhythm Control Strategy in Atrial Fibrillation Patients Presenting at the Emergency Department: The HEROMEDICUS Study Design and Initial Results.

Atrial fibrillation has progressively become a more common reason for emergency department visits, representing 0.5% of presenting reasons. Registry data have indicated that about 60% of atrial fibrillation patients who present to the emergency department are admitted, emphasizing the need for more efficient management of atrial fibrillation in the acute phase. Management of atrial fibrillation in the setting of the emergency department varies between countries and healthcare systems. The most plausible reason to justify a conservative rather than an aggressive strategy in the management of atrial fibrillation is the absence of specific guidelines from diverse societies. Several trials of atrial fibrillation treatment strategies, including cardioversion, have demonstrated that atrial fibrillation in the emergency department can be treated safely and effectively, avoiding admission. In the present study, we present the epidemiology and characteristics of atrial fibrillation patients presenting to the emergency department, as well as the impact of diverse management strategies on atrial-fibrillation-related hospital admissions. Lastly, the design and initial data of the HEROMEDICUS protocol will be presented, which constitutes an electrophysiology-based aggressive rhythm control strategy in patients with atrial fibrillation in the emergency department setting.

Risk factors of emergency department visits following elective cervical and lumbar surgical procedures: a multi-institution analysis from the Michigan Spine Surgery Improvement Collaborative.

Emergency department visits 90 days after elective spinal surgery are relatively common, with rates ranging from 9% to 29%. Emergency visits are very costly, so their reduction is of importance. This study's objective was to evaluate the reasons for emergency department visits and determine potentially modifiable risk factors. This study retrospectively reviewed data queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry from July 2020 to November 2021. MSSIC is a multicenter (28-hospital) registry of patients undergoing cervical and lumbar degenerative spinal surgery. Adult patients treated for elective cervical and/or lumbar spine surgery for degenerative pathology (spondylosis, intervertebral disc disease, low-grade spondylolisthesis) were included. Emergency department visits within 90 days of surgery (outcome measure) were analyzed utilizing univariate and multivariate regression analyses. Of 16,224 patients, 2024 (12.5%) presented to the emergency department during the study period, most commonly for pain related to spinal surgery (31.5%), abdominal problems (15.8%), and pain unrelated to the spinal surgery (12.8%). On multivariate analysis, age (per 5-year increase) (relative risk [RR] 0.94, 95% CI 0.92-0.95), college education (RR 0.82, 95% CI 0.69-0.96), private insurance (RR 0.79, 95% CI 0.70-0.89), and preoperative ambulation status (RR 0.88, 95% CI 0.79-0.97) were associated with decreased emergency visits. Conversely, Black race (RR 1.30, 95% CI 1.13-1.51), current diabetes (RR 1.13, 95% CI 1.01-1.26), history of deep venous thromboembolism (RR 1.28, 95% CI 1.16-1.43), history of depression (RR 1.13, 95% CI 1.03-1.25), history of anxiety (RR 1.32, 95% CI 1.19-1.46), history of osteoporosis (RR 1.21, 95% CI 1.09-1.34), history of chronic obstructive pulmonary disease (RR 1.19, 95% CI 1.06-1.34), American Society of Anesthesiologists class > II (RR 1.18, 95% CI 1.08-1.29), and length of stay > 3 days (RR 1.29, 95% CI 1.16-1.44) were associated with increased emergency visits. The most common reasons for emergency department visits were surgical pain, abdominal dysfunction, and pain unrelated to index spinal surgery. Increased focus on postoperative pain management and bowel regimen can potentially reduce emergency visits. The risks of diabetes, history of osteoporosis, depression, and anxiety are areas for additional preoperative screening.

The efficacy of non-pharmacological and non-pacing therapies in preventing vasovagal syncope: Tilt training, physical counter pressure maneuvers, and yoga - A systematic review and meta-analysis

BackgroundVasovagal syncope (VVS) is a prevalent condition characterized by a sudden drop in blood pressure and heart rate, leading to a brief loss of consciousness and postural control. Recurrent episodes of VVS significantly impact the quality of life and are a common reason for emergency department visits. Non-pharmacological interventions, such as tilt training, physical counter pressure maneuvers, and yoga, have been proposed as potential treatments for VVS. However, their efficacy in preventing VVS remains uncertain. MethodsA systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched up to March 2023 for randomized controlled trials comparing non-pharmacological interventions with control in preventing VVS recurrence. The primary outcome was the recurrence rate of VVS episodes. ResultsA total of 1130 participants from 18 studies were included in the meta-analysis. The overall mean effect size for non-pharmacological interventions versus control was 0.245 (95 % CI: 0.128–0.471, p-value <0.001). Subgroup analysis showed that yoga had the largest effect size (odds ratio 0.068, 95 % CI: 0.018–0.250), while tilt training had the lowest effect size (odds ratio 0.402, 95 % CI: 0.171–0.946) compared to control. Physical counter pressure maneuvers demonstrated an odds ratio of 0.294 (95 % CI: 0.165–0.524) compared to control. ConclusionNon-pharmacological interventions show promise in preventing recurrent VVS episodes. Yoga, physical counter pressure maneuvers, and tilt training can be considered as viable treatment options. Further research, including randomized studies comparing pharmacological and non-pharmacological approaches, is needed to evaluate the safety and efficacy of these interventions for VVS treatment.

Safety and Efficacy of Ureteroscopic Laser Lithotripsy in the Management of Ureteric Calculi in Pregnancy-Experience of a Tertiary Care Center.

Ureteric colic in pregnancy is one of the common non-obstetric reasons for emergency department visits. Ureteric calculi present a significant threat to maternal and fetal health and definitive management often becomes necessary. Our aim is to assess the safety and efficacy of ureteroscopic laser lithotripsy in the management of ureteric stones in pregnancy. This is a prospective observational study of 3years carried at a tertiary referral center. It includes all pregnant patients who underwent ureteroscopic laser lithotripsy for ureteric stones. A total of 29 pregnant patients underwent ureteroscopic laser lithotripsy at our center in 3years. The mean age of patients was 33.5 ± 6.2years, and the mean gestation age at the time of ureteroscopy was 23.34 ± 5.9weeks. The average stone size was 8.3 ± 3.6mm and was predominantly found in upper ureter (62%). The mean operative time was 31 ± 8.9min, and the average laser energy spent was 4.3 ± 1.1kJ/case. There was no major Intraoperative complication, and the average hospital stay was 2.5 ± 1.5days. Complete stone clearance was achieved in 93.1% of cases. Ureteroscopic laser lithotripsy is safe and effective treatment of ureteric stones in terms of obstetric outcome and stone clearance in pregnancy.

Reasons for emergency department visits of patients with opioid use disorder at an urban safety-net hospital: A retrospective records review

Objectives: The purpose of this study was to describe the emergency department (ED) visit chief complaints and discharge diagnoses of patients with an opioid use disorder (OUD) empaneled to a primary care clinic.&#x0D; Design: ED visits were retrospectively reviewed through electronic health records. Patients with a history of using multiple substances and medical or psychiatric conditions were compared to those without these conditions.&#x0D; Setting: This study was conducted at Harbor-UCLA ED, a safety-net level one trauma center.&#x0D; Patients and participants: Eligible participants were empaneled to the Harbor-UCLA Family Health Center with a diagnosis of OUD between January 1, 2018, and December 31, 2020.&#x0D; Main outcome measures: The primary outcome measures included number of ED visits, hospital admissions, chief complaints, and discharge diagnoses.&#x0D; Results: The total number of patients was 59. The most common chief complaints were musculoskeletal (34 percent), gastrointestinal (18 percent), general (13 percent), and skin (8.6 percent). The most common discharge diagnoses were musculoskeletal (27 percent), gastrointestinal (20 percent), infectious (11 percent), substance use disorder related (11 percent), psychiatric (7 percent), and cardiovascular (7 percent). Co-occurring alcohol use was associated with a higher number of visits, 3.18 versus 1.15 (p = 0.021), and a higher percentage of patients with frequent visits, 46 percent versus 8 percent (p = 0.008). Patients with diabetes had more frequent visits, 40 percent versus 10 percent (p = 0.036), and were more likely to be admitted, 43 percent versus 15 percent (p = 0.010).&#x0D; Conclusions: This study highlights the importance of screening and the management of alcohol use and diabetes among patients with OUD.

An evaluation of pediatric emergency cases in the first year of the COVID-19 pandemic: A single-centre experience

AimNurses responsible for the care of children in the emergency department must be aware of the case profile of the pandemic era, better prepare for developing crises, and identify preventive services. The study aims to determine the pediatric emergency cases admitted during the pandemic and compare them to those during the pre-pandemic period. MethodsThe current study was designed as a single-center, retrospective, cross-sectional, and descriptive research. All patients aged between 0 and 18 who presented to the pediatric emergency department and had electronic patient records were included in the research population. The data were gathered over two periods: the pre-pandemic period from 2019 to 2020 and the pandemic period from 2020 to 2021. A total of 145,591 patient records were analyzed. ResultsThe number of admissions declined by 51.6% during the pandemic, and a noticeable difference in the reasons for emergency department visits (p = 0.001) was detected. The pandemic saw a decrease in the cases of respiratory, gastrointestinal diseases, and ear, nose, and throat problems. In contrast, there was an increase in the cases of musculoskeletal system diseases, infections, falls, traumas, and neonatal problems. ConclusionThe number of pediatric emergency cases decreased significantly during the pandemic, and compared to the pre-pandemic period, some changes in these cases were observed. Practical implicationsParticular attention should be given to ensuring that mothers of newborn infants receive adequate nursing care. Nurses working in the emergency department should keep their knowledge up-to-date regarding the changing health issues specific to the pandemic period.

Emergency department visits among patients receiving systemic cancer treatment in the ambulatory setting

BackgroundMost patients receive systemic cancer treatment in the ambulatory setting. However, during their treatment journey, patients experience complications that necessitate emergency department (ED) visits. Few studies evaluated the burden of such visits and their characteristics. This study aimed to evaluate the incidence and characteristics of ED visits among adult cancer patients receiving systemic cancer treatment in the ambulatory setting.MethodsA retrospective observational study was conducted at a comprehensive cancer center in Jordan. Utilizing the medical records database, we identified all patients treated in the chemotherapy infusion units, between January and December 2021. Patients who received only supportive therapy were excluded. The proportion of patients who required ED visits, their characteristics, types of cancer treatments received, and reasons for ED visits were recorded.ResultsOver the study period, 4985 patients received 38,803 treatment cycles in the infusion units. Among those, 2773 (55.6%) patients had 10,061 ED visits. Patients who presented to the ED had a mean age of 53.7 ± 13.8 (SD) years and 1763 (63.6%) were females. The most common types of malignancies were breast (39.5%) and gastrointestinal (20%). The most common cancer treatments associated with ED visits were platinum-based (24.8%), immune-mediated/targeted therapy (15.3%), and hormonal (12.3%). The most common admission diagnoses were neuromuscular/skeletal symptoms (34.8%) and gastrointestinal symptoms (20.2%).ConclusionsIn a large cohort of cancer patients receiving cancer treatment in the ambulatory setting, over half of them required at least one ED visit. Most visits were for neuromuscular/skeletal and gastrointestinal symptoms. Future studies should identify measures to reduce ED visits to enhance the patients’ quality of life and outcomes and optimize resources.

The association between acute otitis externa-related emergency department visits and extreme weather events in a temperate continental climate

BackgroundClimate change is a global challenge that is resulting in an increased occurrence of extreme weather events. Extreme weather events have been shown to negatively impact various health conditions, leading to an overall increase in morbidity and mortality. Ear, nose, and throat (ENT) emergencies are among the most common reasons for emergency department visits (EV). Acute otitis externa (AOE), an inflammatory external auditory canal skin infection, is the second most common condition for ENT-related emergency admissions. Previously, AOE has been associated with higher temperatures during summer; However, no data exists on extreme weather events’ immediate and delayed effects on AOE-related EVs. Identifying these relationships could help predict EVs, optimize health resources, and relieve its significant burden on healthcare systems. ObjectiveThis study aimed to associate the effects of extreme weather events with the immediate and delayed risk of AOE-related EVs. MethodsA total of 1522 AOE-related EVs from the ENT outpatient clinic of the Vienna General Hospital between 2015 and 2018 were analyzed. Meteorological data for the same study period was obtained from the Austrian Central Institution for Meteorology and Geodynamics for Vienna and a distributed lag non-linear model used to associate extreme weather events with the total number of AOE-related EVs. Relative risk (RR) and cumulative RR were analyzed over a period of 14 days. ResultsAOE-related EVs showed a pronounced seasonality, with the highest occurrence in summer. The RR for AOE-related EVs was significantly increased one day after high-temperature events for seven days, to a maximum of 1.95 [1.04–3.65]. Low and high relative humidity significantly reduced the same-day occurrence of AOE-related EVs to 0.65 [0.46–0.92] and 0.74 [0.58–0.95]. Increased precipitation and wind speed significantly decreased the RR of AOE-related EVs four and seven days after occurrence. After one day, low atmospheric pressure events showed an increased RR of 1.42 [1.02–1.98] in AOE-related EVs. ConclusionsExtreme weather events significantly impact AOE-related EVs. While high mean temperatures were positively correlated with AOE-related EVs, low humidity was found to have a negative same-day effect, supporting the idea of multiple factors being involved in increasing the susceptibility for AOE. Knowledge of the pattern of events could allow the implementation of time-optimized prevention strategies to reduce the incidence of AOE, the frequency of EVs, and the burden on health care systems.

Adverse drug reactions in the ambulatory internal patients at the emergency department: Focus on causality assessment and drug-drug interactions.

A non-interventional retrospective study in ambulatory patients was conducted at the emergency department of the Division of internal medicine. In 2 months, 266 suspected adverse drug reactions (ADRs) were identified in 224/3453 patients (6.5 %). In 158/3453 patients (4.6 %), an ADR was the reason for emergency department visit and in 49 patients (1.4 %), ADRs led to hospitalisation. A causality assessment algorithm was developed, which included Naranjo algorithm and levels of ADR recognition by the treating physician and the investigators. Using this algorithm, 63/266 ADRs (23.7 %) were classified as "certain", whereas using solely the Naranjo score calculation, only 19/266 ADRs (7.1 %) were assessed as "probable" or "certain", and the rest of ADRs (namely, 247/266 = 92.9 %) were assessed as "possible". There were 116/266 (43.6 %) ADRs related to potential drug-drug interactions (DDIs), stated in at least one of the literature sources used. Based on the causality relationship, the rate of the clinically expressed DDIs was 19.0 %, or 12/63 "certain" ADR cases. Of these, 10 cases presented serious DDI-related ADRs. In summary, ADR causality assessment based exclusively on Naranjo algorithm demonstrated low sensitivity at an ambulatory emergency setting. Additional clinical judgment, including the opinion of the treating physician, proved necessary to avoid under-rating of the causality relationship, and enabled the determination of clinically expressed DDIs.

Consultations for HIV post-exposure prophylaxis before and after health insurance coverage of pre-exposure prophylaxis to a university-based emergency department in Germany

Background: Potential risk contacts for HIV transmission may lead to presentations to the emergency department (ED) for counseling and initiation of post-exposure prophylaxis (PEP). Objective: To examine the impact of German health insurance covering pre-exposure prophylaxis (PrEP) following Sept 1st 2019 for certain risk groups on the frequency and reasons for PEP counseling in a university-based ED in Germany. Methods: In a before-after study design, all persons aged ≥18 years who presented for PEP counseling were analyzed retrospectively. We compared characteristics of presentations in the 18 months prior to PrEP coverage on Sept 1st, 2019, with those in the following 18 months. Results: 154 ED presentations occurred in the first study period, and 155 ED presentations in the second period. Regarding the reasons for ED visits, no statistically significant difference was found [occupational risk contact (18.2 vs. 26.5%, p = 0.081), sexual risk contact (74.7 vs. 69.0%, p = 0.266), other non-occupational risk contact (7.1 vs. 4.5%, p = 0.329)]. For men who have sex with men (MSM), no statistically significant differences were found [38.9 (n = 60) vs. 35.5% (n = 55), p = 0.537]. All persons presenting to the HIV outpatient clinic after ED PEP initiation (n = 60 vs. n = 52) tested negative for HIV 3 months later. Conclusion: In this study, reasons to present for PEP counseling to a university ED showed no change following the implementation of PrEP coverage by health insurances. Therefore, PEP remains an important prevention for HIV transmission and presentations to the ED for PEP counseling may provide an opportunity to educate persons at risk of HIV infection about PrEP, thereby helping to prevent new HIV infections.

Improved prehospital triage for acute cardiac care: results from HART-c, amulticentre prospective study.

Cardiac symptoms are one of the most prevalent reasons for emergency department visits. However, over 80% of patients with such symptoms are sent home after acute cardiovascular disease has been ruled out. The Hollands-Midden Acute Regional Triage-cardiology (HART-c) study aimed to investigate whether anovel prehospital triage method, combining prehospital and hospital data with expert consultation, could increase the number of patients who could safely stay at home after emergency medical service (EMS) consultation. The triage method combined prehospital EMS data, such as electrocardiographic and vital parameters in real time, and data from regional hospitals (including previous medical records and admission capacity) with expert consultation. During the 6‑month intervention and control periods 1536 and 1376patients, respectively, were consulted by the EMS. The primary endpoint was the percentage change of patients who could stay at home after EMS consultation. The novel triage method led to asignificant increase in patients who could safely stay at home, 11.8% in the intervention group versus 5.9% in the control group: odds ratio 2.31 (95% confidence interval (CI) 1.74-3.05). Of 181patients staying at home, only 1(< 1%) was later diagnosed with ACS; no patients died. Furthermore the number of interhospital transfers decreased: relative risk 0.81 (95% CI 0.67-0.97). The HART‑c triage method led to asignificant decrease in interhospital transfers and an increase in patients with cardiac symptoms who could safely stay at home. The presented method thereby reduced overcrowding and, if implemented throughout the country and for other medical specialties, could potentially reduce the number of cardiac and non-cardiac hospital visits even further.

Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals—A Qualitative Analysis

Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders' perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients' preferences, families' decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.

Statistical and machine learning approaches to predict the necessity for computed tomography in children with mild traumatic brain injury.

Minor head trauma in children is a common reason for emergency department visits, but the risk of traumatic brain injury (TBI) in those children is very low. Therefore, physicians should consider the indication for computed tomography (CT) to avoid unnecessary radiation exposure to children. The purpose of this study was to statistically assess the differences between control and mild TBI (mTBI). In addition, we also investigate the feasibility of machine learning (ML) to predict the necessity of CT scans in children with mTBI. The study enrolled 1100 children under the age of 2 years to assess pre-verbal children. Other inclusion and exclusion criteria were per the PECARN study. Data such as demographics, injury details, medical history, and neurological assessment were used for statistical evaluation and creation of the ML algorithm. The number of children with clinically important TBI (ciTBI), mTBI on CT, and controls was 28, 30, and 1042, respectively. Statistical significance between the control group and clinically significant TBI requiring hospitalization (csTBI: ciTBI+mTBI on CT) was demonstrated for all nonparametric predictors except severity of the injury mechanism. The comparison between the three groups also showed significance for all predictors (p<0.05). This study showed that supervised ML for predicting the need for CT scan can be generated with 95% accuracy. It also revealed the significance of each predictor in the decision tree, especially the "days of life." These results confirm the role and importance of each of the predictors mentioned in the PECARN study and show that ML could discriminate between children with csTBI and the control group.

A population-based study of the direct longitudinal health care costs of upper extremity trauma in patients aged 18-65 years.

Upper extremity (UE) trauma represents a common reason for emergency department visits, but the longitudinal economic burden of this public health issue is unknown. This study assessed the 3-year attributable health care use and expenditure after UE trauma requiring acute surgical intervention, with specific focus on injuries that affect function of the hand and wrist. We conducted an incidence-based, propensity score-matched cohort study (2006-2014) in Ontario, Canada, using linked administrative health care data to identify case patients and matched control patients. We matched adults with hand, wrist and UE nerve trauma requiring surgery 1:4 to control patients. We compared total direct health care costs, including 1-year pre-index costs, between case and control patients using a differences-in-difference methodology. The primary outcome was attributable health care costs within 3 years of injury. We matched patients with trauma (n = 26 123) to noninjured patients (n = 104 353). Mean direct health care costs attributable to UE trauma were $9210 (95% confidence interval [CI] 8880 to 9550) within 3 years. Patients with trauma had significantly more emergency department visits (≥ 3 visits: 25% v. 12%; p < 0.001), mental health visits (34% v. 28%; p < 0.05) and secondary surgeries (25% v. 5%; p < 0.001). Specific patient populations had significantly greater attributable costs: patients requiring post-traumatic mental health visits ($11 360 v. $7090; p < 0.001), inpatient surgery ($14 060 v. $5940, p < 0.001) and complex injuries ($13 790 v. $7930; p < 0.001). Health care expenditure increased more than fivefold in the year after UE trauma surgery and remained greater than the matched cohort for the subsequent 2 years. Those with more serious injuries and post-injury visits for mental health were associated with higher costs, requiring further study for this public health issue. The mean 1-year pre-injury and 1-year post-injury total costs were $1710 and $9350, respectively.

Adult asthma exacerbation: emergency room management

Asthmatic exacerbations (AEs) are a frequent reason for emergency department visits. Management should be guided by the severity of the attack but should also focus on patient education and prevention of future exacerbations. This article summarizes current recommendations for the management of both simple and life-threatening AE. When the clinical evolution is favorable, and the patient no longer presents any criteria of severity or risk factors for decompensation, a return home can be considered, with appropriate treatment and the organization of outpatient follow-up. However, if the patient's prognosis is likely to be engaged, transfer to an intensive care unit should not be delayed, to ensure optimal care.

Ninety-Day Emergency Department Visits After Ankle Fracture Surgery.

Emergency department (ED) visits after orthopaedic procedures such as ankle fracture open reduction and internal fixation (ORIF) have received less attention than other outcomes. This study analyzed 90-day ED visits after ankle fracture surgery in a national database to better characterize the incidence, timing, risk factors, and reasons. Ankle fractures undergoing ORIF were extracted from the PearlDiver M91Ortho 2010 to 2020Q3 data set. Patients were excluded for age younger than 18 years, presence of concomitant fractures, and <90 days of database follow-up. Patient age, sex, Elixhauser Comorbidity Index score, region of the country, and insurance plan were analyzed as predictors for 90-day ED utilization using multivariate logistic regression. Incidence of readmissions and incidence, timing, risk factors, and reasons for ED visits were determined. Of 87,662 ankle fracture ORIF patients identified, ED visits were noted within 90 days of surgery for 10,087 (11.5%) while 4,030 (4.6%) were readmitted. One ED visit was noted for 6,102 patients, two visits for 2,654, three visits for 787, and more than three visits for 544. The greatest weekly incidence of ED visits was observed in weeks 1 and 2, with 2.9% and 3.1% of the entire cohort visiting in each week respectively. Factors independently associated with 90-day ED utilization included younger age (odds ratio [OR] 1.21 per decade decrease, P < 0.001), greater Elixhauser Comorbidity Index score (OR 1.40 per two-point increase, P < 0.001), and Medicaid insurance (OR 1.92, P < 0.001). In the first two postoperative weeks, 71% of ED visits were attributed to issues directly involving the surgical site while in subsequent weeks, most visits did not involve the surgical site (65%). Many patients visit the ED after ankle fracture surgery. The greatest ED utilization was during the first two postoperative weeks, and reasons for visits were defined. These findings have implications for optimizing care pathways and targeting resource allocation.

Clean Shot: Bacterial Contamination After Positive Pressure Irrigation of Low-Velocity Gunshot Wounds.

Low-velocity gunshot wounds (LV-GSWs) are a common reason for emergency department visits. Optimal nonsurgical treatment has not been thoroughly studied and is not standardized. The goal of this study was to determine whether positive pressure irrigation reduces the bacterial contamination after a simulated GSW to soft tissue. Nineteen lamb shank specimens were prepared with denim inoculated with Serratia marcescens cultures. A 9-mm pistol round was fired from a distance of 3 m through the contaminated denim into the lamb shank. A culture swab was placed in the wound directly after firing, after 250 cubic-centimeters (cc) irrigation with normal saline, and after an additional 250 cc irrigation (for a total of 500 cc). Swabs were then cultured to determine the amount of bacterial growth. Before irrigation, 0 (0%) plates showed no growth, 2 (10.5%) showed rare growth, 8 (42.1%) showed few growth, 6 (31.6%) showed moderate growth, and 3 (15.8%) showed many growth. After 500 cc irrigation, 2 (10.5%) showed no growth, 1 (5.3%) showed rare growth, 11 (57.9%) showed few growth, 2 (10.5%) showed moderate growth, and 3 (15.8%) showed many growth. Fisher exact test confirmed no significant change in bacterial concentration after irrigation ( P = 0.59). A Pearson test found no correlation between irrigation and bacterial growth (r = -0.15, P = -0.25). Positive pressure irrigation with up to 500 cc normal saline did not significantly alter the quantity of bacterial growth within a simulated GSW cavity. The data suggest that bedside positive pressure irrigation may not be beneficial in the initial emergency department treatment of LV-GSWs.

Impact of COVID-19 on emergency department use among home care recipients

Abstract Background The impact of COVID-19 pandemic on Emergency Department (ED) was remarkable throughout Europe. We focused upon ED utilization among integrated home care (IHC) recipients comparing ED between pandemic period with pre-pandemic (February -December 2020 and 2019, respectively) in Piedmont, Italy. Methods A retrospective observational study was conducted. All recipients of IHC during the two periods studied were enrolled and all ED visits that occurred among IHC recipients were accounted for. Several variables related to IHC admission, reason of ED visits and demographic characteristics were collected. The average of ED visits in pre-pandemic and pandemic periods were calculated. Analyses were stratified by all variables. Results Patients enrolled were 11968 in 2019 and 8938 in 2020. In 2019, 3573 patients had at least one ED visit and 1668 patients in 2020. Number of ED visits was 5503 in 2019 and 2197 in 2020. The average of ED visits in 2020 has reduced in comparison with 2019 (0.464 C.I. [0.44-0.489] and 0.24 C.I. [0.227-0.252], p &amp;lt; 0.001 in 2019 and 2020 respectively). This reduction is regardless of sex, age, duration of IHC, presence of a non-family caregiver or reason for ED visits, except for abdominal pain, cardiac rhythm alteration and gynaecological symptoms. The averages of ED visits were significantly lower for IHC recipients with neoplasm (0.549 C.I. [0.513-0.585] and 0.328 C.I. [0.298-0.358], p &amp;lt; 0.001, and with low level of emergency (1.77 C.I. [1.662-1.877] and 1.397 C.I. [1.348-1.447], p &amp;lt; 0.036), but an increase in mortality rate was not registered. Conclusions Our results showed a reduction of ED visits among integrated home care recipients in pandemic period in comparison with pre-pandemic period. If the reduction can be the consequence of an unprepared health service that needs of necessary changes in its organization, these results suggest a great potential of the home care system to reduce the use of the hospital especially for low-risk conditions. Key messages • The COVID-19 pandemic overwhelmed health services of all European Countries. A reduced utilization of ED has been shown by literature, especially during the early phase of the COVID-19 pandemic. • We showed a reduction in IHC recipients and a great decrease in ED visits among IHC patients in 2020 versus 2019, mainly in oncological patients, while an increase in mortality rate was not reported.

Reasons for Emergency Department Visit, Outcomes, and Associated Factors of Oncologic Patients at Emergency Department of Jimma University Medical Centre.

The number of oncologic patients visiting the emergency department (ED) is increasing and represent a challenge for the emergency team owing to they might have acute sign and symptoms of a still undiagnosed malignancy, management of treatment-related side effects, co-morbidities, and palliative care. Thus, this study was aimed to identify reasons for ED visits, management outcomes, and associated factors of oncologic patients. A prospective cross-sectional study was conducted from March 11, 2021 to August 25, 2021 at the ED of Jimma University Medical Center on a total of 338 oncologic patients. Data were collected from the patient and the patient's medical record using a questionnaire developed from up-to-date similar literatures. The questionnaire was started filled out upon diagnosis of cancer and completed during discharge from the ED. The outcomes of the patients were dichotomized into died and survived then, it was analyzed using frequency and bivariate logistic regression. The most common reasons for oncologic patients ED visit were neutropenic fever 79 (23.4%) followed by vomiting 38 (11.2%) and electrolyte abnormality 37 (10.9%) respectively. Among oncologic patients visited ED, 137 (40.5%) of them were admitted to ward and 126 (37.3%) of them were discharged with improvement while 64 (18.9%) of them were died. Based on multivariate logistic regression, those patients who had distant metastasis cancer (AOR 1.85; 95% CI 1.03-7.21), comorbidity (AOR 2.56; 95% CI 1.20, 6.96), and ECOG >3 (AOR 2.40; 95% CI 1.25,13.43) were more likely to die than their counterparts. Most of the oncologic patients visited ED due to neutropenic fever, nausea and or vomiting, and electrolyte disorder. Amongst oncologic patients who were visited ED, most of them were admitted to ward while around one-fifth of them were died. Having distant metastasis cancer, comorbidity and ECOG >3 were independent predictors of an oncologic patient's outcome at the ED.