Recent Emergency Department Visit Research Articles

Older adult drug overdose: an application of latent class analysis to identify prevention opportunities

BackgroundOlder adult overdose death rates have increased significantly in recent years. However, research for prevention of drug overdose death specific to older adults is limited. Our objective is to identify profiles based on missed intervention points (touchpoints) to inform prevention of future older adult unintentional overdose deaths.MethodsWe used latent class analysis methods to identify profiles of decedents aged 55 + years in the Illinois Statewide Unintentional Drug Overdose Reporting System. This system collects data on 92.6% of all unintentional overdose deaths in Illinois and includes data from death certificates, coroner/medical examiner, toxicology, and autopsy reports. Data include decedent demographics, circumstances leading up to and surrounding the fatal overdose and details regarding the overdose. Variables in the latent class analysis model included sex, race, alcohol test result, social isolation, recent emergency department (ED) visit, chronic pain, and pain treatment.ResultsWe identified three distinct decent profiles. Class 1 (13% of decedents) included female decedents who were in pain treatment, had physical health problems, and had greater likelihood of a recent ED visit before their death. Class 2 (35% of decedents) decedents were most likely to be socially connected (live with others, employed, had social or family relationships) but less likely to have recent healthcare visits. Class 3 (52% of decedents) decedents had higher social isolation (lived alone, unemployed, unpartnered), were mostly male, had fewer known physical health conditions, and more alcohol positivity at time of death. White decedents are clustered in class 1 while Black decedents are predominant in classes 2 and 3.ConclusionsThese profiles link to potential touchpoint opportunities for substance use disorder screening harm reduction and treatment. Class 1 members were most likely to be reachable in healthcare settings. However, most decedents were members of Classes 2 and 3 with less engagement in the healthcare system, suggesting a need for screening and intervention in different contexts. For Class 2, intervention touchpoints might include education and screening in work or social settings such as senior centers given the higher degree of social connectivity. For Class 3, the most isolated group, touchpoints may occur in the context of harm reduction outreach and social service delivery.

Perspectives of Black Patients on Racism Within Emergency Care

Numerous Black individuals experience racism persistently throughout their lives, with repercussions extending into health care settings. The perspectives of Black individuals regarding emergency department (ED) care, racism, and patient-centered approaches for dismantling structural racism remain less explored. To qualitatively explore the perspectives and experiences of Black patients related to race, racism, and health care following a recent ED visit. In this qualitative study, the audio from semistructured interviews of Black patients discharged from an academic urban ED between August 2021 to April 2022 were recorded, transcribed, and analyzed using thematic analysis. The main outcomes encompassed the main themes from the analysis of the interviews with Black patients regarding their perspectives on race, racism, and clinical care. A total of 25 Black patients (20 [80%] female; mean [SD] age, 44.6 [12.9] years) discharged from the ED were interviewed. Three broad domains were identified: (1) racism in health care; (2) ED clinical care; and (3) recommendations for improvement. Within these domains, the first 2 were grouped into specific themes. Within the first domain, racism in health care, 7 themes were identified using thematic analysis: (1) a history of medical racism; (2) dismissiveness; (3) patient expectations on encountering racism; (4) medical mistrust; (5) health literacy; (6) postencounter outcomes, and (7) discrimination beyond but associated with race. Within the second theme, ED clinical care, 5 themes were identified using the same thematic analysis method: (1) discharge plan; (2) patient experience; (3) waiting room perceptions; (4) medication treatment; and (5) pain management. The third domain, recommendations for improvement, incorporated patient-generated suggestions for enhancing the Black patient experience. In this qualitative study, the fabric of clinical care delivery in the ED was intricately woven with Black patients' experiences of racism. Patients expressed a pervasive sense of mistrust, skepticism, and dismissiveness at the system level. Instances of racism were consistently highlighted by patients from their entry to the ED to discharge. These perspectives illuminate the pervasive nature of racism in clinical care, providing valuable insights for exploring patient-centered approaches to foster antiracist cultures in the ED and throughout the broader medical landscape.

PATTERNS AND ASSOCIATED FACTORS OF OBJECTIVE INFLAMMATION ASSESSMENT TO TREAT-TO-TARGET: DATA FROM THE IBD QORUS COLLABORATIVE

Abstract BACKGROUND A Treat-to-Target (T2T) strategy for inflammatory bowel disease (IBD) improves clinical outcomes. The cornerstone of T2T is the routine assessment of objective markers of inflammation to determine treatment efficacy. Despite this, objective testing is often delayed or not performed. This study aims to describe patterns and associated factors of intended assessment of objective markers of inflammation for patients with IBD within the multicenter quality improvement collaborative, IBD Qorus. METHODS Patient and provider survey data from IBD Qorus were prospectively collected from 6/2021 to 10/2022 across 35 academic and community practices during routine clinical care visits. Patients with unknown status of mucosal healing were excluded. The primary outcome of "timely assessment" was defined as provider-reported intent to obtain fecal calprotectin (FC), imaging, or endoscopy within 12 months. Factors associated with the primary outcome were assessed using univariate and multivariate logistic regression, adjusting for age, gender, IBD type, and clinical factors. RESULTS 4,831 encounter-level surveys from the study period were included for analysis. In 73.9% of encounters, providers reported an intent to assess inflammation within the next 6 months. Of these, 77.1% planned to use FC and 57.7% imaging or endoscopy. 89.3% of visits noted an intent to assess inflammation within 12 months. Providers reported in 29.8% of encounters that patients declined FC and in 8.3% that imaging or endoscopy were declined. In the primary univariate analysis, intent for timely assessment was associated with ulcerative colitis (UC), recent emergency department visit or hospitalization, lack of clinical remission, mild Provider Global Assessment, current steroid use, lack of immunomodulator use, lack of steroid-free mucosal healing, care at an academic site, and intent to change therapy. On multivariate analyses, UC (OR 1.38, 95% CI 1.11-1.71), steroid use (OR 2.1, 95% CI 1.1-4.6), and plans to change therapy (OR 1.84, 95% CI 1.2-2.9) remained significantly associated with higher odds of timely assessment. In contrast, steroid-free mucosal healing (OR 0.52, 95% CI 0.41-0.66) and care in community practice (OR 0.63, 95% CI 0.51-0.77) remained significantly associated with lower odds of timely assessment. CONCLUSION In IBD Qorus, there is a strong intent to assess objective markers of inflammation. However, lower odds of intended assessment were found among patients with Crohn’s, patients in steroid-free mucosal healing, and those receiving care in community practice, revealing potential care gaps. Interestingly, providers frequently reported that patients declined FC testing, and declined this at higher rates than that for endoscopy or imaging. This study identifies potential areas to improve testing for inflammation under a T2T strategy.

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults.

We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients. We performed a retrospective case control study from June 1-August 31, 2019 (pre-program) to September 24, 2019-January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables. A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41-0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14-0.50). Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.

The Implementation of a Virtual Emergency Department: Multimethods Study Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) Framework.

While the COVID-19 pandemic dramatically increased virtual care uptake across many health settings, it remains significantly underused in urgent care. This study evaluated the implementation of a pilot virtual emergency department (VED) at an Ontario hospital that connected patients to emergency physicians through a web-based portal. We sought to (1) assess the acceptability of the VED model, (2) evaluate whether the VED was implemented as intended, and (3) explore the impact on quality of care, access to care, and continuity of care. This evaluation used a multimethods approach informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data included semistructured interviews with patients and physicians as well as postvisit surveys from patients. Interviews were transcribed and analyzed using thematic analysis. Data from the surveys were described using summary statistics. From December 2020 to December 2021, the VED had a mean of 153 (SD 25) visits per month. Among them, 67% (n=677) were female, and 75% (n=758) had a family physician. Patients reported that the VED provided high-quality, timely access to care and praised the convenience, shorter appointments, and benefit of the calm, safe space afforded through virtual appointments. In instances where patients were directed to come into the emergency department (ED), physicians were able to provide a "warm handoff" to improve efficiency. This helped manage patient expectations, and the direct advice of the ED physician reassured them that the visit was warranted. There was broad initial uptake of VED shifts among ED physicians with 60% (n=22) completing shifts in the first 2 months and 42% (n=15) completing 1 or more shifts per month over the course of the pilot. There were no difficulties finding sufficient ED physicians for shifts. Most physicians enjoyed working in the VED, saw value for patients, and were motivated by patient satisfaction. However, some physicians were hesitant as they felt their expertise and skills as ED physicians were underused. The VED was implemented using an iterative staged approach with increased service capabilities over time, including access to ultrasounds, virtual follow-ups after a recent ED visit, and access to blood work, urine tests, and x-rays (at the hospital or a local community laboratory). Physicians recognized the value in supporting patients by advising on the need for an in-person visit, booking a diagnostic test, or referring them to a specialist. The VED had the support of physicians and facilitated care for low-acuity presentations with immediate benefits for patients. It has the potential to benefit the health care system by seeing patients through the web and guiding patients to in-person care only when necessary. Long-term sustainability requires a focus on understanding digital equity and enhanced access to rapid testing or investigations.

Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia

Collaborative dementia care programs are effective in addressing the needs of patients with dementia and their caregivers. However, attempts to consider effects on health care spending have been limited, leaving a critical gap in the conversation around value-based dementia care. To determine the effect of participation in collaborative dementia care on total Medicare reimbursement costs compared with usual care. This was a prespecified secondary analysis of the Care Ecosystem trial, a 12-month, single-blind, parallel-group randomized clinical trial conducted from March 2015 to March 2018 at 2 academic medical centers in California and Nebraska. Participants were patients with dementia who were living in the community, aged 45 years or older, and had a primary caregiver and Medicare fee-for-service coverage for the duration of the trial. Telehealth dementia care program that entailed assignment to an unlicensed dementia care guide who provided caregiver support, standardized education, and connection to licensed dementia care specialists. Primary outcome was the sum of all Medicare claim payments during study enrollment, excluding Part D (drugs). Of the 780 patients in the Care Ecosystem trial, 460 (59.0%) were eligible for and included in this analysis. Patients had a median (IQR) age of 78 (72-84) years, and 256 (55.7%) identified as female. Participation in collaborative dementia care reduced the total cost of care by $3290 from 1 to 6 months postenrollment (95% CI, -$6149 to -$431; P = .02) and by $3027 from 7 to 12 months postenrollment (95% CI, -$5899 to -$154; P = .04), corresponding overall to a mean monthly cost reduction of $526 across 12 months. An evaluation of baseline predictors of greater cost reduction identified trends for recent emergency department visit (-$5944; 95% CI, -$10 336 to -$1553; interaction P = .07) and caregiver depression (-$6556; 95% CI, -$11 059 to -$2052; interaction P = .05). In this secondary analysis of a randomized clinical trial among Medicare beneficiaries with dementia, the Care Ecosystem model was associated with lower total cost of care compared with usual care. Collaborative dementia care programs are a cost-effective, high-value model for dementia care. ClinicalTrials.gov Identifier: NCT02213458.

Patient perceptions of microaggressions and discrimination toward patients during emergency department care.

Disparities in emergency department (ED) care based on race and ethnicity have been demonstrated. Patient perceptions of emergency care can have broad impacts, including poor health outcomes. Our objective was to measure and explore patient experiences of microaggressions and discrimination during ED care. This mixed-methods study of adult patients from two urban academic EDs integrates quantitative discrimination measures and semistructured interviews of discrimination experiences during ED care. Participants completed demographic questionnaires and the Discrimination in Medical Settings (DMS) scale and were invited for a follow-up interview. Transcripts of recorded interviews were analyzed leveraging conventional content analysis with line-by-line coding for thematic descriptions. The cohort included 52 participants, with 30 completing the interview. Nearly half the participants were Black (n = 24, 46.1%) and half were male (n = 26, 50%). "No" or "rare" experiences of discrimination during the ED visit were reported by 22/48 (46%), some/moderate discrimination by 19/48 (39%), and significant discrimination in 7/48 (15%). Five main themes were found: (1) clinician behaviors-communication and empathy, (2) emotional response to health care team actions, (3) perceived reasons for discrimination, (4) environmental pressures in the ED, and (5) patients are hesitant to complain. We found an emergent concept where persons with moderate/high DMS scores, in discussing instances of discrimination, frequently reflected on previous health care experiences rather than on their current ED visit. Patients attributed microaggressions to many factors beyond race and gender, including age, socioeconomic status, and environmental pressures in the ED. Of those who endorsed moderate to significant discrimination via survey response during their recent ED visit, most described historical experiences of discrimination during their interview. Previous experiences of discrimination may have lasting effects on patient perceptions of current health care. System and clinician investment in patient rapport and satisfaction is important to prevent negative expectations for future encounters and counteract those already in place.

A qualitative study of people who use methamphetamine during the early COVID-19 pandemic to inform future ED harm reduction strategies

BackgroundMorbidity and mortality rates related to methamphetamine are on the rise. Simultaneously, social-distancing guidelines were issued in March 2020 to decrease transmission of COVID-19. The aim of this study was to explore concerns regarding methamphetamine use during the COVID-19 pandemic and subsequent harm reduction strategies with patients who use methamphetamine to inform emergency department (ED)-based harm reduction approaches.MethodsA mixed-methods study of adults residing in Washington with high-risk methamphetamine use and a recent ED visit from April-September 2020 was performed. Participants completed a survey and a semi-structured interview on perceptions and experiences of COVID-19. Descriptive statistics were used for survey responses. Interview transcripts were analyzed and guided by modified grounded theory using an iterative approach to refine the guide and codebook. Interviews were independently coded by 2 investigators and discussed until consensus.ResultsTwenty-five participants completed the survey; 20 participants were interviewed (45% recently used heroin, 40% unstably housed). Thirty-five percent was worried about COVID-19 infection. Three themes emerged from the interviews: (1) increase in meth use, (2) interplay of meth obtention and COVID-19, and (3) interactions with healthcare and social services.ConclusionsPeople who use methamphetamine noted an increase in use along with the social distancing guidelines put in place for COVID-19 and employed a variety of harm reduction profiles when obtaining methamphetamine. Also, the pandemic brought difficulties in accessing care and amplified mistrust in healthcare instructions and public health messages. Based on these qualitative interviews, further work should consider aligning methamphetamine and COVID-19 harm reduction messages and working with trusted community resources to improve harm reduction strategies for methamphetamine use and COVID-19. IRB: Informed Consent by the University of Washington Human Subjects Division (approval number, STUDY00009277).

The impact of follow-up calls after a pediatric emergency department visit

Pediatric emergency department (ED) visits can be a stressful time for patients and their caregivers. This high stress environment can lead to questions and needed clarifications post-discharge. We implemented a post-discharge callback system to resolve these concerns for a focused subset of patients who historically have provided the most negative comment feedback on ED patient experience surveys. We hypothesized that comment types would shift to more positive than negative and the themes of the comments received would change. We developed a discharge callback process that focused on patients who were triaged as ESI level 4 during their emergency department visit. Over a 6-week period, patients were called the day after discharge and asked if they had questions regarding their recent ED visit in addition to questions regarding current health, post-discharge instructions, prescriptions, or follow-up instructions if applicable. A maximum of 3 discharge calls were made if needed in order to contact the patient or family. Any questions regarding health care needs were followed up by a licensed healthcare provider within 24 hours with a maximum of 3 attempts. At the end of the project timeframe we analyzed comments received from our patient experience surveys to identify if there was a shift in comment types and their themes. In addition, we analyzed ED return rates within 72 hours of discharge. During the 6-week period, 2710 calls were made to contact 1618 patients’ caregivers. Follow up was requested by 149 families with a healthcare provider. There was no significant change in the number of comment types received. Thematic analysis of the patient experience survey comments received during this time period, revealed a reduction in questions regarding the recent ED visit and post discharge needs. There was no significant change in 72-hour ED return rates. The institution of an ED discharge callback system can effectively reduce patients’ and families’ questions regarding post-discharge care by providing an opportunity to clarify care after they have left the emergency department.

Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial

BackgroundVisits to the emergency department (ED) are inflection points in patients’ illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes.MethodsThis is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL.DiscussionIn seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients’ self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes.Trial registrationClinicalTrials.gov identifier: NCT05209880

Psychological distress among medically complex veterans with a recent emergency department visit.

Medical complexity and psychological distress are associated with frequent emergency department (ED) use. Despite this known association, our understanding is limited about which patients are at risk for persistent psychological distress and what patterns of distress emerge over time. A secondary data analysis was used to examine self-reported psychological distress (defined as ≥14 unhealthy days due to poor mental health in the past month) at 30 and 180 days following enrollment in a randomized control trial of 513 medically complex Veterans after a nonpsychiatric ED visit. We used a multivariable ordered logistic regression model to examine the association of a priori factors [baseline psychological distress, age, race, income, health literacy, deficits in activities of daily living (ADL), and deficits in instrumental activities of daily living] with three psychological distress classifications (no/low, intermittent, and persistent). Among 513 Veterans, 40% reported at baseline that they had experienced high psychological distress in the previous month. Older age was associated with lower odds of high psychological distress (OR = 0.95; 95% CI: 0.94-0.97). Baseline factors associated with significantly higher odds of persistent psychological distress at 30 and 180 days assessments, included having the inadequate income (OR = 1.61; 95% CI: 1.02-2.55), having low health literacy (OR = 1.63; 95% CI: 1.01-2.62), and reporting at least one ADL deficit (OR = 1.94; 95% CI: 1.13-3.33). Psychological distress at follow-up was common among medically complex Veterans with a recent ED visit. Future research should explore interventions that integrate distress information into treatment plans and/or link to mental health referral services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Nausea and vomiting during pregnancy leading to nystagmus, ataxia, and maternal brain injury

A 30-year-old primigravida with a single intrauterine pregnancy at 16+1 weeks’ gestation based on last menstrual period (and consistent with an 11-week ultrasound) presented to the emergency department (ED) with protracted nausea and vomiting. Although the patient had not received prenatal care, she had been evaluated in the ED for nausea and vomiting at 11 and 14 weeks’ gestation. She was discharged home from the most recent ED visit after tolerating oral intake and receiving a combination of intravenous (IV) antiemetics and oral potassium repletion.

Obstructive sleep apnea and nocturnal attacks of paroxysmal atrial fibrillation.

Obstructive sleep apnea (OSA) is commonly seen in patients with atrial fibrillation (AF), but it is unclear to what extent this relationship is one of causation or association. We examined a cohort of patients with paroxysmal AF to determine whether the presence of OSA (apnea-hypopnea index ≥ 15 events/h) affects the time of onset of symptomatic AF episodes. Patients with a recent emergency department visit for a symptomatic episode of paroxysmal AF were recruited from an AF clinic. The time of onset of the AF attack was classified as occurring in "sleeping hours" or "waking hours" based on direct history from the patient and emergency department visit documentation. Of 152 patients with paroxysmal AF, 67 underwent polysomnography; 1 (1.5%) had central sleep apnea, 46 (68.7%) had mild or no OSA, and 20 (29.8%) had OSA. In the OSA group, 14/20 (70.0%) had their symptomatic AF attack during sleeping hours compared to 12/46 (26.1%) in the mild or no OSA group (P = .001). Compared with those who had a paroxysmal AF attack during waking hours, and adjusting for confounders, those who had a paroxysmal AF attack during sleeping hours had almost 6 times the odds of having OSA (odds ratio, 5.53; P = .007). Compared to patients with paroxysmal AF with mild or no OSA, those with OSA were far more likely to have a symptomatic AF attack during sleeping hours, supporting a causal role for OSA in the pathogenesis of AF in this population. These findings strongly suggest that patients who have nocturnal AF attacks should be evaluated for OSA. Lin C-H, Timofeeva M, O'Brien T, Lyons OD. Obstructive sleep apnea and nocturnal attacks of paroxysmal atrial fibrillation. J Clin Sleep Med. 2022;18(5):1279-1286.

“Pain in the Neck”: Acute-Onset Neck Pain in an Adolescent Girl

A 10-year-old girl presents to the pediatric emergency department (ED) with acute onset of sharp neck pain and torticollis that began on awakening the morning of presentation. She has had shoulder pain for the past 3 days and in addition developed pain in her neck the morning of presentation. This morning she developed numbness in her legs and inability to walk. She has no associated headache, dizziness, fever, or urinary or bowel incontinence.She had a recent ED visit for flank pain due to constipation treated with polyethylene glycol 9 days earlier. Her medical history includes asthma and eczema. She is fully immunized. She has had a 12-lb (5.4-kg) weight loss in the previous 7 weeks.Her initial vital signs are as follows: temperature, 98.8°F (37.1°C); pulse, 104 beats/min; blood pressure, 138/91 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 100% on room air. She is generally well-appearing but in acute distress secondary to neck pain. She is lying in bed holding her neck laterally flexed to the right, refusing to move it, and she cries out in pain with any attempt to move her head to midline. She has abdominal tenderness with normal bowel sounds and no hepatosplenomegaly or masses. Her neurologic examination is significant for 3/5 strength in the upper extremities and inability to move the lower extremities spontaneously except toe wiggling. Sensation is intact throughout. She has a flexor plantar response bilaterally, but no deep tendon reflexes could be elicited in her upper or lower extremities. She is refusing to sit up or move in bed due to neck pain.A complete blood cell count, comprehensive metabolic panel, C-reactive protein level, and creatine phosphokinase level were all normal.Neck pain, a common chief complaint in the pediatric ED, is most often musculoskeletal, traumatic, or infectious in origin. The typical etiologies include muscular spasm; cervical spine injury; peritonsillar, retropharyngeal, or other deep neck abscess; and meningitis or epidural abscess. Less commonly, neck pain can be secondary to arthritis, congenital malformations, vertebral anomalies, and posterior fossa or cervical spinal tumors. (1) It is important to take a thorough history with attention to the timing and specific characteristics of pain, including quality, radiation, aggravating or relieving factors, and any associated symptoms to help build a differential diagnosis and determine the need for radiologic and laboratory investigation. (2)Neurology was consulted and recommended gabapentin and ketorolac treatment for pain. She was admitted for further evaluation and management. The following day she was noted to have normal strength and reflexes in the upper extremities but 2/5 strength, hypotonia, and absent reflexes in the lower extremities, including absent Babinski sign. She also developed urinary retention requiring Foley catheter placement. Magnetic resonance imaging (MRI) of the brain and complete spine was performed and demonstrated a solidly enhancing lesion in the thoracic cord at T5-T6 through T6-T7 with a peripherally enhancing single cystic component extending cranially to approximately C5 (Fig 1). There were areas of hypointensity in the upper thoracic portion consistent with hemorrhage, as well as T2 hyperintensity extending cranially to the craniocervical junction (Fig 2) and caudally to the conus (Fig 3), consistent with edema. Neurosurgery was consulted and recommended dexamethasone treatment to reduce edema. The patient was brought to the operating room for laminoplasty and tumor resection, after which she experienced lower extremity paralysis and urinary incontinence. Surgical pathology demonstrated a diffuse midline glioma, H3 K27M mutation (World Health Organization grade IV). Oncology discussed treatment options with the family and noted that

Risk factors for hyperthermia mortality among emergency department patients

PurposeThis study examines risk factors for heat-related mortality due to hyperthermia in emergency department patients, a vulnerable population. MethodsThis matched case-control study used statewide, longitudinally linked emergency department (ED) data and death records from California. Cases comprised California residents (≥18 years) who presented to a state-licensed ED and died of hyperthermia during the study period (2009–2012). For each case, up to five ED patients were randomly selected as live controls and matched on sex and age. Patients’ demographic characteristics and history of ED utilization for alcohol use, drug use, psychiatric disorders, heart-related conditions, chronic respiratory disease, neurodegenerative disorders, and cerebrovascular disease were assessed in relationship to hyperthermia mortality. ResultsUsing multivariate conditional logistic regression models, hyperthermia mortality cases had higher odds of prior ED utilization for alcohol use (OR = 11.16, 95% CI = 3.87, 32.17) compared to controls. Cases were also more likely than controls to have Medicare insurance (OR = 5.80, 95% CI = 1.70, 15.15) or self-pay (OR = 5.39, 95% CI = 1.73, 16.79), at their most recent ED visit. ConclusionsED patients presenting with alcohol problems may face increased risk of hyperthermia mortality. To help reduce heat-related mortality, EDs should consider interventions that target patients vulnerable to heat exposure.

Factors associated with opioid overdose during medication-assisted treatment: How can we identify individuals at risk?

BackgroundDue to the loss of tolerance to opioids during medication-assisted treatment (MAT), this period may represent a time of heightened risk for overdose. Identifying factors associated with increased risk of overdose during treatment is therefore paramount to improving outcomes. We aimed to determine the prevalence of opioid overdoses in patients receiving MAT. Additionally, we explored factors associated with opioid overdose during MAT and the association between length of time enrolled in MAT and overdose.MethodsData were collected prospectively from 2360 participants receiving outpatient MAT in Ontario, Canada. Participants were divided into three groups by overdose status: no history of overdose, any lifetime history of overdose, and emergency department visit for opioid overdose in the last year. We used a multivariate multinomial regression model to assess demographic and clinical factors associated with overdose status.ResultsTwenty-four percent of participants reported a lifetime history of overdose (n = 562), and 8% reported an emergency department (ED) visit for opioid overdose in the last year (n = 179). Individuals with a recent ED visit for opioid overdose were in treatment for shorter duration (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.87, 0.97, p = 0.001). Individuals with a lifetime or recent history of overdose were more likely to be younger in age (OR 0.93, 95% CI 0.89, 0.98, p = 0.007 and OR 0.84, 95% CI 0.77, 0.92, p < 0.001, respectively), report more physical symptoms (OR 1.02, 95% CI 1.01, 1.03, p = 0.005 and OR 1.03, 95% CI 1.01, 1.05, p = 0.005, respectively), and had higher rates of non-prescription benzodiazepine use (OR 1.87, 95% CI 1.32, 2.66, p < 0.001 and OR 2.34, 95% CI 1.43, 3.81, p = 0.001, respectively) compared to individuals with no history of overdose.ConclusionsA considerable number of patients enrolled in MAT have experienced overdose. Our study highlights that there are identifiable factors associated with a patient’s overdose status that may represent areas for intervention. In particular, longer duration in MAT is associated with a decreased risk of overdose.

Gender, socioeconomic status and emergency department visits among cancer survivors in the USA: a population-based study.

Aim: To assess patterns of emergency department visits and subsequent hospitalization in relation to gender and socioeconomic status among a cohort ofcancer survivors in the USA. Materials & methods: National Health Interview Surveydatasets (2011-2017) were reviewed and participants with a history of cancer and complete information about emergency department visits in the past 12months were included. Multivariable logistic regression analyses were used to assess factors associated with emergency department visits and subsequent hospitalization after the most recent emergency department visit. Results: A total of 22,240 cancer survivors were included in the current analysis; of which 16,133 participants (72.5%) who have not visited an emergency department in the past 12months and 6107 participants (27.5%) who have visited an emergency department in the past 12months. Multivariable logistic regression analysis suggested the following factors are associated with emergency department visits; younger age (odds ratio [OR] with increasing age: 0.98; 95% CI: 0.98-0.99), female gender (OR: 1.07; 95% CI: 1.00-1.15), African American race (OR: 1.26; 95% CI: 1.13-1.40), unmarried status (OR for married vs unmarried: 0.79; 95% CI: 0.74-0.84), lower yearly earnings (OR: 1.36; 95% CI: 1.20-1.54), poor health status (OR: 7.02; 95% CI: 6.02-8.18) and incomplete health insurance coverage (OR for complete coverage vs incomplete coverage: 0.66; 95% CI: 0.54-0.80). On the other hand, the following factors were associated with subsequent hospitalization: older age (OR: 1.004; 95% CI: 1.000-1.008), male gender (OR for female vs male: 0.86; 95% CI: 0.78-0.94), unmarried status (OR for married vs unmarried status: 0.80; 95% CI: 0.73-0.88), not working (OR: 1.44; 95% CI: 1.23-1.68), lower yearly earnings (OR: 1.31; 95% CI: 1.07-1.60), poor health status (OR: 8.43; 95% CI: 6.76-10.51) and lack of health insurance coverage (OR for complete coverage vs incomplete coverage: 0.71; 95% CI: 0.55-0.93). Conclusion: Female cancer survivors were more likely to visit the emergency department, whereas they were less likely to be subsequently hospitalized. Cancer survivors with lower socioeconomic status were more likely to visit emergency departments and to be subsequently hospitalized.

Patient Markers of Successful Diabetes Management.

For individuals with diabetes, diabetes health status may not align with A1C targets. Patients may use nonclinical targets when assessing their diabetes management success. Identifying these targets is important in developing patient-centered management plans. The purpose of this study was to identify patient markers of successful diabetes management among patients in an urban academic health system. A secondary analysis of semistructured interviews was completed with 89 adults with type 1 or type 2 diabetes. Participants had a recent diabetes-related emergency department (ED) visits or hospitalization or were primary care patients with an A1C >7.5%. Interviews were conducted to saturation. Demographic data were collected via self-report and electronic medical records. Interviews were analyzed using conventional content analysis. This analysis focused on patient perceptions of successful management coded to "measuring management success." Although most participants cited A1C or blood glucose as a marker of successful diabetes management, they had varied understanding of these metrics. Most used a combination of targets from the following categories: 1) A1C, blood glucose, and numbers; 2) engagement in medical care; 3) taking medication and medication types; 4) symptoms; 5) diet, exercise, and weight; and 6) stress management and social support. Individuals not meeting glycemic goals and/or with recent diabetes-related ED visits or hospitalizations had varied understanding of A1C and blood glucose targets. They use multiple additional markers of successful management and had a desire for management discussions that incorporate these markers. These measures should be incorporated into their care plans along with clinical targets.

A Multiple Case Study of Coordinated Care for Children with IBD through Caregiver Interviews.

Effective care coordination is critical to manage unpredictable complications of conditions such as pediatric inflammatory bowel disease (IBD) that have a relapsing and remitting course. Our objective was to explore perspectives of care coordination following emergency department (ED) visits by children with IBD, because these may indicate deficient care coordination. Using a multiple case study approach, we sought perspectives through semi-structured interviews of caregivers (parents, primary care providers, and gastroenterologists) for children with IBD who had a recent ED visit in either of two large pediatric referral centers in the southeastern US. We used criterion sampling to identify eligible participants through a medical record report of ED visits, and iterative sampling concurrent with analysis until no new themes were identified. Interviews were transcribed verbatim, and transcripts were coded using directed content analysis to identify emergent themes. From twenty-six interviews, three major themes emerged: perceptions of appropriate expertise, desire for integration of information and services, and making assumptions instead of engaging. Participants describe distinct roles for primary care and gastroenterology providers and recognize communication and information barriers to better coordination. Some parents and gastroenterologists perceive challenges to engaging primary care providers. Common recommendations include explicit guidance from gastroenterologists to primary care providers and methods for direct communication. Stakeholders describe common barriers and facilitators for effective care coordination, but some express beliefs about provider roles that could hinder improvement efforts. Tools to support asynchronous communication and shared planning may improve coordination and care quality for complications of IBD.

The impact of a Housing First intervention and health-related risk factors on incarceration among people with experiences of homelessness and mental illness in Canada.

To examine the effect of a Housing First (HF) intervention and health-related risk factors on incarceration among adults with experiences of homelessness and mental illness. Participants (N = 508) were recruited at the Toronto site of the At Home/Chez Soi study. The outcome was incarceration in Ontario from 2009 to 2014. Exposures were intervention group (HF vs. treatment as usual), Axis I mental health diagnoses, emergency department (ED) visit, and history of traumatic brain injury (TBI). Logistic regression was used to examine the association between exposures and incarceration. Of 508 participants, 220 (43.3%) were incarcerated at least once during the study period. Among those incarcerated, 81.9% were male, 52.7% had been diagnosed with alcohol dependence/abuse, 60.9% had been diagnosed with substance dependence/abuse, 65.1% reported having visited an ED within the last 6months, and 66.4% had a history of TBI. After adjusting for demographic covariates, substance dependence/abuse (aOR: 2.06; 95% CI: 1.40, 3.03), alcohol dependence/abuse (aOR: 1.52, 95% CI: 1.04, 2.22), ED visit (aOR: 1.54; 95% CI: 1.02, 2.32), and history of TBI (aOR: 2.60; 95% CI: 1.75, 3.85) were associated with incarceration. We found no significant effect of the HF intervention on incarceration outcome (aOR: 1.08; 95% CI: 0.76, 1.55). Among adults with experiences of homelessness and severe mental illness, those with substance and alcohol dependence/abuse disorders, history of TBI, and recent ED visits were at increased odds of incarceration. Strategies are needed to prevent and reduce incarceration for this population, including treatment of mental illness in the community.