Recurrent Emergency Department Research Articles

The impact of different anticoagulants and antiplatelets regimens on acute epistaxis outcomes.

The impact of anticoagulants (AC) and antiplatelets (AP) on the management of acute epistaxis remains unclear. This study investigated the association between AC/AP therapy and treatment outcomes in patients with acute epistaxis. A retrospective analysis of patients presented to the otolaryngology emergency room with acute epistaxis (2014-2022). Patients were categorized based on their regular medications: AP, dual AP therapy (DAPT), new oral anticoagulants (NOAC), vitamin K antagonists (VKA), or no regular AC/AP use (control group). Outcome measures included rates of minor interventions (chemical or electrical cautery, nasal tamponade), major interventions (endoscopic ligation, embolization), recurrent emergency department visits, admission rates, and duration. 786 patients were included with an average follow-up period of 52.56 ± 20.4 months. Compared to the control group, patients on AP, DAPT, or VKA had significantly higher rates of minor interventions (63.1% vs. 74.4%, 79.6%, and 77.3%, respectively, p < 0.05). DAPT users exhibited a higher rate of major interventions than the control (5.6% vs. 1.3%, p = 0.053). NOAC users showed no significant difference in minor interventions compared to control and required no major interventions. Both NOAC and VKA users had significantly higher rates of recurrent epistaxis events and prolonged hospitalization compared to the control (p < 0.01 and p < 0.05, respectively). NOAC demonstrated more favorable outcomes than VKA in patients with acute epistaxis, and DAPT use was associated with an increased need for major interventions. These findings suggest a more conservative approach in NOAC users than other AC/AP agents.

Diabetes-related hypoglycemia, contributing risk factors, glucagon prescriptions in two community hospitals

IntroductionHypoglycemia has long been recognized as a dangerous adverse effect of the treatment of diabetes mellitus with insulin or insulin secretagogues. ObjectiveOur study was aimed to identify the number of diabetic patients presenting to the emergency department (ED) with hypoglycemia, contributing risk factors for hypoglycemia (including antidiabetic medication regimens), the number of episodes of hypoglycemia requiring medical attention, and how many patients were prescribed glucagon at discharge. Study designOur study is a retrospective analysis across two hospitals from October 2019 to March 2022, including the population of adult persons with diabetes mellitus, above 18 years of age, presenting to the emergency department with hypoglycemia. ResultsOf the women were 2 African Americans, 25 Caucasians, 17 Hispanics, and 39 from other ethnicities. Of the men were 8 African Americans, 32 Caucasians, 27 Hispanics, and 44 from other ethnicities. The mean age of males was 66.2 years, and females was 72.9 years. 131 patients had no prior visits for hypoglycemia. Of the 194 patients, 54 were discharged from the ED, and 140 were admitted to the hospital. The most common risk factors associated with hypoglycemia requiring medical attention were age > 65, having more than one comorbidity, decreased oral intake, and poor socioeconomic status. Regarding recurrent presentations with hypoglycemia, there was a significant association with insulin use (p-value = 0.0007), with a higher-than-expected number of insulin users having a previous visit for hypoglycemia. Only 16.7 % of non-insulin-using patients had prior visits, compared to 40.6 % of insulin users. Pairwise Chi-square testing did not reveal a significant association between any other medication class and prior visits for hypoglycemia, nor was there an association between risk factors and prior visits. To obtain optimal glycemic control, early identification of hypoglycemia risk factors, self-monitoring of blood glucose, and proper selection of anti-diabetic regimens are important to prevent long-term complications. ConclusionUnfortunately, the three elements that would prevent subsequent severe hypoglycemic events (i.e., education, adjustment of medication, and glucagon prescription) are underutilized. Hypoglycemia is more common in the elderly population which remains an unmodifiable risk factor. Identifying patients with persistent poor oral intake is extremely important as they may be prone to hypoglycemic episodes on their current anti-diabetic regimen and will need medication adjustments accordingly. Our future research focuses on whether giving glucagon prescriptions to patients with diabetes mellitus at discharge prevents recurrent ED visits for hypoglycemia.

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study.

This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia. Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits. There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14days, access to homecare services, and previous hyperglycemia encounters in the past 5years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group. This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

Aesthetic Surgery Complications Disproportionately Burden Economically Disadvantaged Patients and Financially Strain Public Health Insurance: A Single Academic Center Retrospective Analysis

Abstract Goals/Purpose Complications of elective aesthetic surgery performed in private practice pose significant morbidity to patients and resource burden to healthcare systems. We aimed to characterize contemporary demographic and complication patterns among patients presenting to an academic center after aesthetic surgery, as well as the financial and resource burden of their postoperative care on the hospital and payor. Methods/Technique We performed a retrospective review of patients who presented to an urban, academic hospital emergency department in Northern California from September 1, 2020 to September 30, 2023. We included patients with primary complaints related to aesthetic procedures performed at outside centers resulting in a plastic surgery consultation. Demographics, outcomes, hospital charges, and insurance payments were determined. Univariable analyses identified associations with outcomes. Results/Complications We identified 36 patients with aesthetic procedure-related complaints. Mean age was 37.5 ± 9.8 years and all patients were female. Compared with the rest of the patient population presenting to the emergency department over the same time period (n=269,286), the identified patients were more likely to be black (34.3% vs. 20.4%, p=.04), Hispanic (40% vs. 24.6%, p=.03), and on Medicaid (80.6% vs. 31.7%, p&amp;lt;.001). Tobacco/cannabis use and obesity were prevalent in 25% and 47.2% of patients, respectively. Most patients underwent aesthetic procedures in the United States (51.4%), followed by Mexico (37.1%) and the Dominican Republic (11.4%). Body regions intervened upon were the abdomen (52.8%), breasts (52.8%), buttocks (33.3%), and arms (8.3%). In 36.1% of patients, multiple body regions were intervened upon during the index case. Abdominal cases included primary abdominoplasty (84.2%), panniculectomy (10.5%), and revision abdominoplasty (5.3%). Breast cases were primary augmentation (36.8%), revision augmentation (21.1%), augmentation mastopexy (15.8%), mastopexy only (15.8%), and other (10.5%). Buttocks cases were gluteal fat grafting (63.6%) and implant insertion (36.4%). Arm cases were all brachioplasty. Median postoperative day was 21 (Interquartile Range [IQR] 11.5, 36). Reasons for presentation included infection (44.5%), dehiscence (16.7%), pain (16.7%), seroma/drainage (11.1%), drain management (5.6%), and hematoma (2.8%). Nearly half received computed tomographic imaging (47.2%). Half of patients were admitted with a median length of stay of 2.5 days (IQR 1, 3). One-third underwent intervention, including implant removal (58.3%), image-guided aspiration (25%), and incision and drainage (16.7%). Patients using tobacco/cannabis were more likely to present with infection (88.9% vs. 25.9%, p=.001) and undergo intervention (66.7% vs. 22.2%, p=.01). There were recurrent emergency department visits among 22.2%. Overall, 44.4% of patients had outpatient follow-up visits for a median of 3 (IQR 2, 4) visits up to a median of 38 (IQR 21.5, 70.5) days after consultation. For the index hospital encounter and any subsequent outpatient/emergency visits, the total median hospital charge was $43,324.96 (IQR $10,728.12, $80,803.18) and median insurance payment was $3,947 (IQR $404.61, $24,516.00). In the setting of operative intervention, median hospital charge and insurance payments were $125,358.70 (IQR $51,065.52, $152,704.70) and $14,863.52 (IQR $3,947, $49,031.13), respectively. Conclusion In this case series, the majority of patients presenting with complaints related to aesthetic surgery were economically disadvantaged and nearly half received surgery abroad. Their surgical complications often directly and significantly cost the state-funded health insurance and strained inpatient and outpatient resources. Nearly a quarter of patients were offered aesthetic surgery despite active smoking, and they were more likely to develop infection and receive invasive treatments. While future analysis should aim to replicate our findings in a larger sample, providers and government agencies should warn their vulnerable patients of these risks.

Economics of Emergency Department Visits by Patients With Inflammatory Bowel Disease: A Real-World Analysis.

Inflammatory bowel disease (IBD) is associated with significant psychosocial, economic, and physical burden on patients. IBD care in the United States results in significant healthcare expenditure with recurring emergency department (ED) care and hospital admissions. Despite advances in therapy and improved access to specialty care, there is still room for improvement in cost-efficient care. Specialty medical homes and interdisciplinary care models have emerged as ways to improve medical care, patient outcomes, and quality of life, as well as improve the impact of healthcare costs. There is limited real-world data on cost in the United States, with many articles citing cost estimates from models. We analyzed real-world data from our tertiary care center with a focus on recurrent ED visits by IBD patients. Descriptive statistics were used for a cost analysis of multiple ED visits by IBD patients. Patients with ≥4 visits to the ED in a 6-month period were described as SuperUsers and were included in a separate analysis. The cost of hospitalization was also included. Total cost associated with all ED visits from SuperUsers were $72999.57 with an average of $6636.32 per patient. When the patients were admitted, the total cost of ED visits and hospitalizations was $721461.52, with an average of $65587.41 per patient. ED utilization by IBD patients with or without hospitalization is expensive and is typically driven by a cohort of SuperUsers. More work needs to be done to improve cost-effectiveness in IBD care, including reducing the frequency of ED visits.

Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews.

Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD. Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use. Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use. Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

Association between antithrombotic therapy after stroke in patients with atrial fibrillation and the risk of net clinical outcome: an observational cohort study.

Data on the optimal use of antithrombotic drugs and associated clinical outcomes in patients with atrial fibrillation (AF) and acute ischaemic stroke (IS) are limited. We investigated the prescription patterns of antithrombotics in community practice and long-term clinical prognosis according to early post-stroke antithrombotic therapy in patients with AF and acute IS. Patients with AF who were admitted for acute IS at a single tertiary hospital in 2010-2020 were retrospectively reviewed. Clinical profiles including the aetiology of stroke and prescription patterns of antithrombotics were identified. The net clinical outcome (NCO)-the composite of recurrent stroke, any bleeding, hospitalization or emergency department visits for cardiovascular (CV) events, and death-was compared according to the antithrombotic therapy at the first outpatient clinic visit [oral anticoagulation (OAC) alone vs. antiplatelet (APT) alone vs. OAC/APT(s)] following discharge. A total of 918 patients with AF and acute IS (mean age, 72.6 years; male, 59.3%; mean CHA₂DS₂-VASc score 3.3) were analysed. One-third (33.9%, n = 310) of patients were simultaneously diagnosed with AF and IS. The most common aetiology of IS was cardioembolism (71.2%), followed by undetermined aetiology (19.8%) and large artery atherosclerosis (6.0%). OAC, APT(s), and concomitant OAC and APT(s) were prescribed in 33.4%, 11.1%, and 53.4% of patients during admission that changed to 67.0%, 9.1%, and 21.7% at the first outpatient clinic, and were mostly continued up to one year after IS. Non-prescription of OAC was observed in 11.3% of post-stroke patients with AF. During a median follow-up of 2.1 years, the overall incidence rate of NCO per 100 patient-year (PY) was 20.14. APT(s) monotherapy presented the highest cumulative risk of NCO (adjusted hazard ratio 1.47, 95% confidence interval 1.08-2.00, P = 0.015; with reference to OAC monotherapy) mainly driven by the highest rates of recurrent stroke and any bleeding. OAC/APT(s) combination therapy was associated with a 1.62-fold significantly higher risk of recurrent stroke (P = 0.040) and marginally higher risk of any bleeding than OAC monotherapy. Approximately one-third of acute IS in AF have a distinctive mechanism from cardioembolism. Although APT was frequently prescribed in post-stroke patients with AF, no additive clinical benefit was observed. Adherence to OAC treatment is essential to prevent further CV adverse events in patients with AF and IS.

A Retrospective Cohort Analysis of Mental Health-Related Emergency Department Visits Among Veterans and Non-Veterans Residing in Ontario, Canada: Une analyse de cohorte rétrospective des visites au service d'urgence liées à la santé mentale parmi les vétérans et non-vétérans résidant en Ontario, Canada.

Emergency departments (EDs) are a vital part of healthcare systems, at times acting as a gateway to community-based mental health (MH) services. This may be particularly true for veterans of the Royal Canadian Mounted Police who were released prior to 2013 and the Canadian Armed Forces, as these individuals transition from federal to provincial healthcare coverage on release and may use EDs because of delays in obtaining a primary care provider. We aimed to estimate the hazard ratio (HR) of MH-related ED visits between veterans and non-veterans residing in Ontario, Canada: (1) overall; and by (2) sex; and (3) length of service. This retrospective cohort study used administrative healthcare data from 18,837 veterans and 75,348 age-, sex-, geography-, and income-matched non-veterans residing in Ontario, Canada between April 1, 2002, and March 31, 2020. Anderson-Gill regression models were used to estimate the HR of recurrent MH-related ED visits during the period of follow-up. Sex and length of service were used as stratification variables in the models. Veterans had a higher adjusted HR (aHR) of MH-related ED visits than non-veterans (aHR, 1.97, 95% CI, 1.70 to 2.29). A stronger effect was observed among females (aHR, 3.29; 95% CI, 1.96 to 5.53) than males (aHR, 1.78; 95% CI, 1.57 to 2.01). Veterans who served for 5-9 years had a higher rate of use than non-veterans (aHR, 3.76; 95% CI, 2.34 to 6.02) while veterans who served for 30+ years had a lower rate compared to non-veterans (aHR, 0.60; 95% CI, 0.42 à 0.84). Rates of MH-related ED visits are higher among veterans overall compared to members of the Ontario general population, but usage is influenced by sex and length of service. These findings indicate that certain subpopulations of veterans, including females and those with fewer years of service, may have greater acute mental healthcare needs and/or reduced access to primary mental healthcare.

Concurrent Alcohol and Opioid Intoxication in Emergency Department Patients Leads to Greater Resource Utilization

Background: Concurrent alcohol intoxication can complicate emergency department (ED) presentations for opioid-related adverse events. We sought to determine if there was a difference in resource utilization among patients who presented to the ED with concurrent opioid and alcohol intoxication compared to opioid intoxication alone. Methods: Using linked state-wide databases from the Maryland Healthcare Cost and Utilization Project (HCUP), we identified patients with a diagnosis of opioid intoxication treated in the ED from 2016 to 2018. We measured healthcare utilization for each patient in the ED settings for one year after the initial ED visit and estimated direct costs. We performed logistic regression comparing patients presented with co-intoxication to those without. Results: Of 12,295 patients who presented to the ED for opioid intoxication during the study period, 703 (5.7%) had concurrent alcohol intoxication. Patients with co-intoxication had more recurrent ED visits (340 vs 247.4 per 1000 patients, p < 0.05), higher index ED visit admission rates (26.9% vs 19.4%, p < 0.001), but similar overall costs ($3736 vs $2861, p < 0.05) at one year. Co-intoxication was associated with suicidal ideation (OR = 1.58, 95% CI 1.51–1.65), high zip code income (OR = 1.16, 95% CI 1.12–1.21), and higher rates of intoxication with all classes of drugs analyzed (p < 0.001). Conclusion: Our study demonstrated that mental health disorders, socioeconomic status, and increased ED utilization are associated with co-intoxication of opioids and alcohol presenting to the ED. Further research is needed to elucidate factors responsible for the increased resource use in this population.

Improving outcomes in frail older adults with complex care needs in an ambulatory setting through timely, integrated person-centered care. A case for rapid access frailty clinics in Singapore.

Background: Frailty is a significant risk factor for recurrent hospital admissions and emergency department presentations. Frail older adults are especially vulnerable to hospital related adverse outcomes recognisably functional decline, delirium, institutionalisation and mortality. Fragmentation of care resulting in poorly defined care responsibilities, together with the limitation of community resources to manage acute issues in this group of patients, increase the likelihood of them presenting to an acute care setting.&#x0D; Methods: A retrospective study evaluated frail older adults seen in an ambulatory Geriatric clinic in a government funded public hospital from 2021 to 2022. The aim of the study was to determine if timely evaluation of acute issues in an ambulatory setting could avoid a hospital admission or an emergency department presentation. &#x0D; Results: Preliminary data in this study showed that (1) timely review of acute issues (&lt;1 week from presentation) led to avoidance of hospital admission, emergency department presentation as well as admission in the next 30 days; (2) the common presentations successfully managed include worsening behavioral and psychological symptoms of dementia (BPSD), delirium, infections and falls; (3) majority of the patients seen were moderately to severely frail based on their clinical frailty score (CFS). Additionally, there was high level of patient and caregiver satisfaction reported.&#x0D; Conclusion: This study shows that hospital admissions and emergency department presentations can potentially be avoided in frail older adults whose acute medical issues are recognised and managed early. Important contributing factors to the effective management of these patients include: easy accessibility to the primary geriatrician involved, same day investigations, timely follow ups, good social/family support as well as the engagement of community services. Rapid access frailty clinics, a service model built upon the similar recognition that acute issues in frail older adults needed to be addressed promptly, has been described and shown to have benefit elsewhere. In Singapore, innovations in care delivery both within the hospital and in the community has become ever more crucial with an increasingly frail population and in already overwhelmed healthcare institutions. Rapid access frailty clinics can be a useful hospital-based service delivery model to improve care of our frail older adults.

Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol.

We conducted a population-based, retrospective cohort study of first-time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all-cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. A total of 71,776 AYA had a first-time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First-time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69-3.51). Mortality was associated with age 25-29 years (aHR 3.88, 95% CI 2.56-5.86), being male (aHR 1.98, 95% CI 1.49-2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64-6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96-4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27-3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. Incident ED visits due to alcohol in AYA are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow-up care in this population.

Emergency Department Usage Patterns Among Pediatric Victims of Gun Violence and Physical Assault.

Violent injuries are a common reason for pediatric emergency department (ED) visits, with gun violence being the leading cause of violent death among children. The objective of this study was to assess for patterns of pediatric ED usage that are associated with future ED visits for violent injuries. This case-control study included youths aged 6 to 19 years who presented to a pediatric ED over a 3-year period due to a physical assault (PA) or their first known gunshot wound (GSW). We compared them with age-, race-, and sex-matched youths presenting for nonviolent medical complaints. All previous ED visits were coded as (1) injuries due to a previous PA, (2) mental/behavioral health visits, (3) sexual/reproductive health visits, (4) sexual assault, or (5) concerns for child abuse. We used multivariate logistic regression to identify patterns of previous ED usage associated with future ED visits for injuries related to PA and/or GSW. The PA and GSW groups used the ED for previous PAs, mental/behavioral health, sexual/reproductive health, sexual assault, and/or child abuse concerns on average 4 to 8 times as often as the control group. Previous ED visits for mental/behavioral health (odds ratio [OR] 5), sexual/reproductive health (OR 3), sexual assault (OR 9), and prior PA (OR 8) were predictive of a future ED visit for PA. Male sex (OR 6) and previous ED visits for PA (OR 5) were predictive of a future ED visit for GSW. Two percent of the PA group and 9% of the GSW group returned to the ED with a subsequent GSW in the following 16 to 40 months. Emergency department visits due to interpersonal violence, mental/behavioral health, sexual/reproductive health, and sexual assault are associated with recurrent ED visits for violent injuries. Awareness of patterns of ED usage may aid in identifying patients at high risk for violence and increase opportunities for preventative interventions.

189. Outcomes of High-dose Oral Beta-lactam Step-down Therapy Compared to Alternative Oral Therapy for Bacteremic Urinary Tract Infections

Abstract Background Pyelonephritis and associated bacteremia are often treated with intravenous antibiotics followed by oral step-down therapy to a fluoroquinolone (FQ) or trimethoprim/sulfamethoxazole (TMP/SMX). Oral beta-lactams were historically utilized less often due to concern for treatment failure. Literature suggests oral beta-lactams are effective, but there are no preferred oral beta-lactam agents or dosing recommendations. This study evaluates outcomes of high-dose oral beta-lactam therapy for Enterobacterales bacteremia due to a urinary tract infection (UTI) compared to alternative therapy. Methods A retrospective, multicenter, observational cohort study was conducted evaluating patients admitted from February 1, 2020, to October 1, 2022, with gram-negative bacteremia from a urinary source. Adult patients were included if they received empiric intravenous antibiotic active against the bacteria isolated and transitioned to appropriately dosed oral cephalexin, amoxicillin, TMP/SMX, or FQ (Table 1). Excluded were patients who received less than 72 hours of oral therapy, had a diagnosis of renal abscess or lobar nephronia, and those who expired during admission. The primary outcome compared the composite of recurrent bacteremia or mortality within 30 days of completing oral therapy. Secondary outcomes included recurrent UTI, emergency department (ED) or hospital readmission, and Clostridioides difficile infections within 30 days of treatment completion. Results There were 194 patients who met inclusion criteria. The primary outcome occurred in 1/75 (1.3%) patients in the oral beta-lactam group and 2/119 (1.7%) patients in the FQ or TMP/SMX group (p=1.0). Two patients in the FQ or TMP/SMX expired within 30 days and 1 patient in the beta-lactam group had a recurrent bacteremia. There were 16 (21.3%) and 14 (11.8%) patients in the beta-lactam and FQ or TMP/SMX group, respectively, treated for recurrent UTI (p=0.073). Twenty (27%) patients in the beta-lactam group required ED re-evaluation or hospital readmission compared to 30 (25%) patients who received a FQ or TMP/SMX (p=0.74). Zero patients had a Clostridioides difficile infection. Conclusion Oral beta-lactams are as effective as oral FQ and TMP/SMX for the treatment of bacteremia from a urinary source. Disclosures All Authors: No reported disclosures

Risk factors for recurrent emergency care utilization for flares in inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) need frequent emergency care due to flares of their disease. However, understanding which patients are most vulnerable to repeat emergency care due to recurrent flares of their disease remains poor. This was a retrospective cohort study of Kaiser Permanente Northern California health plan members aged ≥18 years between 2009 and 2018. Our primary outcome was occurrence of repeat emergency department (ED) visits with a primary diagnosis code of IBD in the 6 months following their index ED visit. Baseline characteristics and clinical service use patterns were extracted. We used multivariable negative binomial regression analysis to measure the incident risk of a recurrent ED visit within 6 months. We found 2111 patients who met eligibility criteria, of whom 56.7% were female and 39.7% were non-White. During the 6-month observation period, 19.3% (n = 408) returned to the ED for a second IBD flare. In adjusted analyses, we found older age (incident risk ratio [IRR] 0.44, 95% confidence interval [CI] 0.31-0.62 for age 60+ compared to 18-30), higher neighborhood household income (IRR 0.80, 95% CI 0.65-0.98 for income ≥$85,000), and diagnosis of alcohol use disorder were associated with a lower risk of repeat ED utilization (IRR 0.62, 95% CI 0.41-0.93), while presence of mood disorder (IRR 1.26, 95% CI 1.03-1.58), history of opiate prescription (IRR 1.38, 95% CI 1.10-1.73), and corticosteroid prescription (IRR 1.57, 95% CI 1.27-1.95) were associated with increased risk of repeat ED utilization. Prompt outpatient follow-up was not associated with a lower odds of recurrent ED utilization (IRR 0.93, 95% CI 0.75-1.15). Our study identified multiple patient characteristics associated with higher recurrent short-term use of the ED for IBD care. Although we did not find prompt outpatient follow-up after initial ED visit to be protective, targeted interventions directed at high-risk individuals based on mood disorders, opiate use, or steroid use may help to optimize care and health care utilization.

Evaluation of the Retrospective LACE Index in Predicting the Risk of Readmission in Patients with Hereditary Angioedema in an Emergency Department.

This study aimed to calculate the LACE index in patients who admitted to the emergency department (ED) with hereditary angioedema (HA) diagnosed and to predict recurrent admissions of patients. In this single-center study, patients aged 18 or higher who were admitted to the ED diagnosed with HA were included over a 12-year period. 35 patients diagnosed with code E88.0 were evaluated according to electronic file records. The number of admissions to the ED in the last 6 months was 2. The LACE index was 4, and risk was 71.4%. The patients admitted to the hospital in the last 30 days had a higher rate of admission to the hospital in the last 6 months (p < 0.001). The LACE index at admission predicted 30 days admission with (AUC = 0.75, 95% CI (0.56-0.91)) acceptable discrimination. The LACE index and the number of admissions in the last 6 months included in the evaluation can be considered predictive in recurrent ED admissions of HA patients. However, the distribution of LACE-risk groups is no priority. Therefore, the low-, medium-, or high-risk level of LACE index values should be not taken into consideration in readmission of such patients.

Cannabis use and cyclical vomiting syndrome: An open debate

IntroductionCyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS. MethodsThis is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission. ResultsPrimary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = −0.53 days, 95% CI: −0.68 to −0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54–0.73). DiscussionCannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.

Frailty and emergency department utilisation in adults with systemic lupus erythematosus ≤65 years of age: an administrative claims data analysis of Medicaid beneficiaries

ObjectiveFrailty is a risk factor for adverse health in adults with SLE, including those <65 years. Emergency department (ED) utilisation is high in adults with SLE, but to our knowledge,...

Cannabinoid hyperemesis syndrome: Clinical trajectories and patterns of use three months following a visit to the emergency department.

Cannabinoid hyperemesis syndrome (CHS) is a clinical condition of cyclic vomiting, nausea, and abdominal pain associated with chronic cannabis use. Despite increased recognition of CHS, there are limited details on cannabis use practices and symptoms over time. Understanding what happens in the period surrounding the emergency department (ED) visit, including any changes in symptoms and cannabis use practices following the visit, can help inform the development of patient-centered interventions around cannabis use disorder for patients with CHS. A prospective observational cohort (n = 39) of patients with suspected CHS recruited from the ED at the time of a symptomatic cyclic vomiting episode was followed for 3 months. Disease progression, cannabis use practices, and health care utilization were monitored. Participants reported high rates of persistent CHS symptoms (abdominal pain, nausea, or cyclic vomiting) in the 2-week period immediately following an ED visit with a median duration of 7 days. Cannabis use frequency and quantity were reduced immediately after the ED visit, but most participants returned to pre-ED visit cannabis use patterns within a few days. Recurrent ED visits for cyclic vomiting were reported by 25% of participants who completed follow-up during the 3-month follow-up period. Participants continued to have ongoing symptoms after the ED visit, but most managed symptoms on their own and did not return to the ED. Longitudinal studies beyond 3 months are needed to better understand the clinical course of patients with suspected CHS.

Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study.

Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits. We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk. Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines. History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.

Recurrent myocardial infarction and emergency department visits: a retrospective study on the Stockholm Area Chest Pain Cohort

BackgroundPatients who experience acute myocardial infarction (AMI) are at risk of recurrent AMI. Contemporary data on recurrent AMI and its association with return emergency department (ED) visits for chest pain...