Emergency Department Referrals Research Articles

Alcohol use disorder treatment delivered outside hepatology clinic.

Alcohol use disorder treatment delivered outside hepatology clinic.

Appropriateness of lumbar spine radiography and factors influencing imaging ordering patterns: paving the path toward value-driven health care.

The demand for diagnostic imaging continues to rise. Against the backdrop of rising health care costs and finite resources, this has prompted a paradigm shift toward value-driven patient care. Inappropriate imaging is a barrier toward achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral Emergency Department (ED) and assess whether physicians' specialization and years of experience influence appropriateness. A total of 1030 lumbar spine radiographs performed in the ED of an academic medical center over a consecutive 3-month period were reviewed retrospectively. Referral indications were reviewed for adherence to 2021 American College of Radiology appropriateness guidelines for lower back pain, and referral patterns were evaluated among physician groups based on specialists' training and years in practice. 63.8% of lumbar spine radiographs were appropriate, with trauma being the most common indication. 36.2% of orders were inappropriate, with lower back pain of <6 weeks duration being the most common indication. Significant differences in inappropriate orders were found (P < .001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in training (27.8%), and non-specialists with ≥3 (60.0%) and <3 (36.9%) years in practice, respectively. Approximately one-third of lumbar spine radiographs performed in the ED were inappropriately ordered by American College of Radiology guidelines; specialists training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce health care costs.

5613436 EXPERT CONSENSUS ON THE MANAGEMENT OF INFUSION-RELATED REACTIONS (IRRS) PRESENTING WITH PAIN IN PATIENTS RECEIVING CRIZANLIZUMAB

Background: Sickle cell disease (SCD) is characterized by the presence of sickle hemoglobin, hemolytic anemia, and multi-organ and vaso-occlusive complications that can significantly decrease quality of life.[1] Crizanlizumab, a monoclonal antibody, has been shown to reduce the rate of vaso-occlusive crises (VOCs) compared to placebo in patients ≥16 years with SCD.[2] However, there have been reports of patients experiencing severe pain and subsequent complications within 24 hours of crizanlizumab infusions, and these events are defined as infusion-related reactions (IRRs).[3] IRRs are rare, and most clinicians will have limited experience managing them. Aims: Develop clinical guidelines on the management of IRRs presenting with pain in SCD patients receiving crizanlizumab. Methods: We used the RAND/UCLA modified Delphi process. We convened a geographically diverse, experienced 10-member US physician panel (5 pediatric hematology, 4 adult hematology, 1 transfusion medicine) and reviewed evidence on the management of painful IRRs related to crizanlizumab in patients with SCD. We collaboratively developed a rating form made up of 204 hypothetical patient scenarios assessing how to monitor and treat IRRs that present with new or worsening pain. For each of these scenarios, which described different clinical characteristics (e.g., typical vs atypical SCD pain location, pain severity compared to patient’s typical SCD crisis), we asked how to monitor vital signs, when to change infusion speed or discontinue the infusion, which medications to add, which laboratory tests to order, and whether to escalate care (e.g., emergency department referral). Physicians completed ratings both before and after a virtual meeting in June 2022, during which areas of disagreement were discussed. Consensus was defined as being present when no more than two panelists gave a response that differed significantly from the other 8 panelists. Results: Expert recommendations on how to manage IRRs presenting with pain are delineated in Figure 1. When a patient presents with either chest pain of the same severity or pain in any location more severe than their typical SCD crisis, experts recommend continuous vital sign monitoring, stopping the infusion, ordering laboratory tests including a complete blood count, reticulocyte count, and electrolyte and liver function panels, and escalating post-infusion care. Pain should be treated per a patient’s individualized pain plan or other pain management guidelines. Experts do not recommend treating IRRs that present with pain with IV antihistamines or corticosteroids, which can worsen pain and provoke VOCs. Summary/Conclusion: These recommendations outline how to evaluate and manage IRRs presenting with pain in patients receiving crizanlizumab. A valid, reproducible method was used to develop these guidelines, based on expert consensus informed by current literature and clinical experience. Future research should validate this guidance using clinical data and identify patients at risk for these IRRs.

MP70-17 IMPLEMENTATION OF AN ED NEPHROLITHIASIS PROTOCOL INCREASES USE OF MEDICAL EXPULSIVE THERAPY IN THE PEDIATRIC POPULATION

You have accessJournal of UrologyCME1 Apr 2023MP70-17 IMPLEMENTATION OF AN ED NEPHROLITHIASIS PROTOCOL INCREASES USE OF MEDICAL EXPULSIVE THERAPY IN THE PEDIATRIC POPULATION Daniel Salevitz, Chung-Yon Lin, Bernice Alcanzo, Abhijeet Namjoshi, Philip Lee, Cecilia Monteilh, and Gwen Grimsby Daniel SalevitzDaniel Salevitz More articles by this author , Chung-Yon LinChung-Yon Lin More articles by this author , Bernice AlcanzoBernice Alcanzo More articles by this author , Abhijeet NamjoshiAbhijeet Namjoshi More articles by this author , Philip LeePhilip Lee More articles by this author , Cecilia MonteilhCecilia Monteilh More articles by this author , and Gwen GrimsbyGwen Grimsby More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A review of children presenting to our emergency department (ED) from 2011 to 2017 found that ureteral stone passage was significantly higher for those prescribed medical expulsive therapy (MET), versus analgesics alone (45% vs 20%, p<0.0001). Urology consultation was also associated with increased MET use (p<0.0001). As a result, a new nephrolithiasis management protocol was implemented at our ED in August 2017 with the goal of increasing MET usage, decreasing use of CT scans, and increasing outpatient referrals to Urology and Nephrology. METHODS: This is a retrospective study of children aged 2 months to 18 years old who presented to a quaternary children’s hospital ED with an ICD-9 or ICD-10 diagnosis of urolithiasis from August 2017 to April 2022. Basic demographics, MET prescribing, use of CT for stone diagnosis, opioid prescription rate, and referral to Urology and Nephrology were compared before and after implementation of the ED nephrolithiasis protocol. Statistical analysis was performed using two sample t-test analysis and Fisher’s exact test. RESULTS: A total of 124 patients met inclusion criteria. Mean age was 14 years (SD 3.64), 47 (38%) male. Comparing pre and post-protocol implementation, there was no difference in mean age, gender, or stone size between groups (Table 1). Post-protocol, 99 patients (80%) were prescribed MET, which was significantly higher compared with 54% prior to the protocol (p<0.0001). Patients prescribed MET were older (mean 16 vs 15, p=0.014), and a higher proportion were discharged from the ED (71% vs 48%, p=0.033). Post protocol significantly less patients were prescribed opioids (27% vs 44%, p=0.0069). There was no difference in use of CT scans (79% vs 70%, p=0.1169), return to the ED (14% vs 14%, p=0.8681), outpatient urology (89% vs 89%, p=1.0) or nephrology referrals (23% vs 22%, p=1.0) pre and post protocol implementation, Table 1. CONCLUSIONS: After implementation of an ED nephrolithiasis protocol, use of MET for ureteral stones increased and prescription of opioids decreased. There was no difference in use of CT scans or outpatient referral to Urology and Nephrology pre versus post-protocol. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1010 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Salevitz More articles by this author Chung-Yon Lin More articles by this author Bernice Alcanzo More articles by this author Abhijeet Namjoshi More articles by this author Philip Lee More articles by this author Cecilia Monteilh More articles by this author Gwen Grimsby More articles by this author Expand All Advertisement PDF downloadLoading ...

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators.

Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360min) is associated with poor outcomes in this cohort of ED referrals. This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64min (IQR 35-105min). Age ≥ 65years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034). Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.

Safety of Multifood Oral Immunotherapy in Children Aged 1 to 18 Years at an Academic Pediatric Clinic

Oral immunotherapy (OIT) aims to increase the reaction threshold to a food allergen and decrease the risk of a potentially life-threatening allergic reaction in the event of an accidental ingestion. Whereas single-food OIT is the most extensively studied, data on multifood OIT are limited. Our study aimed to examine the safety and feasibility of single-food and multifood immunotherapy in a large cohort in an outpatient pediatric allergy clinic setting. A retrospective review of patients enrolled in single-food and multifood OIT between September 1, 2019, and September 30, 2020, and data collection of those patients until November 19, 2021, were performed. There were 151 patients who underwent either an initial dose escalation (IDE) or a standard oral food challenge. Seventy-eight patients were receiving single-food OIT with 67.9% reaching maintenance. Fifty patients were undergoing multifood OIT with 86% reaching maintenance to at least 1 OIT food and 68% reaching maintenance for all their foods. Of the 229 IDEs, there were low frequencies of failed IDEs (10.9%), epinephrine administration (8.7%), emergency department referrals (0.4%), and hospital admission (0.4%). Cashew accounted for one-third of failed IDEs. Epinephrine administration during home dosing occurred in 8.6% of patients. Eleven patients discontinued OIT owing to symptoms during up-dosing. No patients discontinued once reaching maintenance. Desensitization to 1 food or multiple foods simultaneously through OIT appears to be safe and feasible using the OIT protocol that has been established. The most common adverse reaction causing discontinuation of OIT was gastrointestinal symptoms.

Influence of COVID-19 Pandemic on Colorectal Cancer Presentation, Management and Outcome during the COVID-19 Pandemic.

The aim of the study was to investigate whether the COVID-19 pandemic and related measures had an influence on colorectal cancer (CRC) presentation, management, and outcomes; it was a retrospective monocentric study. CRC patients undergoing surgery during the COVID-19 pandemic (1 March 2020-28 February 2022) (group B) were compared with patients operated on in the previous two years (1 March 2018-29 February 2020) in the same unit (group A). The primary outcome was to investigate whether there were differences in concern regarding the stage at presentation, as a whole and after dividing groups based on cancer location (right colon cancer, left colon cancer, rectal cancer). Secondary outcomes included differences in the number of patients admitted from emergency departments and emergency surgeries between periods, and differences in the postoperative outcomes. A subanalysis within the pandemic group was conducted on the same outcomes, dividing the aforementioned group based on pandemic trends. Two hundred and eighty (280) were operated on during the study period: 147 in group A and 133 in group B. Stage at presentation was similar between groups; however, the subgroups analysis showed that in the pandemic group, the number of early-stage left colon cancer occurrences almost halves, yet not significantly. Emergency department referral was more common in group B (p-value: 0.003); in group B, they also had longer operations and there was a more frequent use of ostomy. No differences in the number of postoperative complications nor in the postoperative outcomes were found. Patients with CRC were more frequently referred through the emergency department during the COVID-19 pandemic and left-sided cancers appear to be generally diagnosed at a more advanced stage. Postoperative outcomes showed that high specialized colorectal units can deliver standard high-level treatment under high-pressure external conditions.

Evaluating patient flow through an emergency ophthalmology consult service in a tertiary care academic centre in Quebec

ObjectiveThis study aims to characterize the epidemiology, common reasons, and diagnostic accuracy of referrals made by emergency departments (EDs) and optometrists to an emergency ophthalmology consultation service as well as to identify opportunities for improvement. DesignRetrospective chart review. ParticipantsA total of 1249 referrals made to the emergency ophthalmology consultation service at a tertiary care centre between July 2018 and June 2019. MethodsPatient charts were examined, and clinical variables were extracted. Statistical significance (p < 0.05) was determined via t tests and χ2 tests for continuous and categorical variables, respectively. Diagnostic accuracy of providers and time delay between referral and ophthalmologic encounter also were assessed. ResultsBoth EDs and optometrists most often referred cases with vitreoretinal (36.48% and 37.19%, respectively) and corneal pathology (21.42% and 20.25%, respectively). Optometrists (n = 240; 52.48%) were significantly more accurate in their diagnoses than EDs (n = 940; 32.45%; p < 0.00001). Specifically, optometrists were significantly more accurate when diagnosing anterior-chamber (n = 29; 58.62%; p = 0.039) and vitreoretinal (n = 89; 60.67%; p < 0.00001) pathology than EDs (anterior chamber, n = 77, 36.36%; vitreoretinal, n = 344, 18.90%). Across all ED referrals (n = 940), 58 (6.17%) had a prolonged delay. Across all optometrist-to-ED referrals (n = 150), 6 (4.00%) had a prolonged delay. Accounting for all cases, the total incidence of prolonged delay was 5.87%. ConclusionsOur results demonstrate the need for improved communication between optometrists and ophthalmologists to reduce the wait-time burden on EDs. Patients may benefit from direct referral by optometrists to ophthalmologists. Education of allied health professionals on ophthalmic disease also may improve diagnostic accuracy.

Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis.

Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions. The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20th - March 2nd, 2020. Patient groups were "routine-hours" (RH): weekdays 07:00-18:59 or "out-of-hours" (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used. 734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis. Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.

Evaluating urgent care center referrals to the emergency department.

Urgent care centers (UCCs) are increasingly popular with an estimated number of 9600 stand-alone centers in the United States compared to emergency departments (EDs). These facilities offer a potentially more convenient and affordable option for patients seeking care for a variety of low-acuity conditions. Because of the limitations of UCCs, patients occasionally are referred to EDs for further care. Prior studies have attempted to evaluate the appropriateness of these UCC referrals. Our study is the first to consider if these referrals require ED-specific care and the diagnostic concordance of these referrals. We performed a retrospective chart review to identify patients who were referred from UCCs to our ED between October 2020 and June 2021. We used a Boolean search strategy to screen charts for the terms urgent care, emergency department, referral, or transfer. Cases were manually screened until 300 met the inclusion criteria. Cases had to feature the patient being seen by a UCC provider and directly referred to the ED on the same day. Patients who presented to the ED of their own volition were excluded. Three independent abstractors reviewed the charts. All abstractors and a senior investigator piloted the use of a data collection sheet and discussed the management of any ambiguous data. A senior physician reviewed all discrepancies among abstractors. Data collected included ED final diagnosis and whether the final diagnosis was similar to the UCC diagnosis. A referral was deemed to require ED-specific care and resources if (1) the patient was admitted, (2) imaging (other than an x-ray) was performed, (3) specialist consultation was required, or (4) care was provided in the ED that is not conventionally available at UCCs. From the 300 patient charts, 55% of patients referred from UCCs to the ED did not require ED-specific care or resources and 64% had discordant diagnoses between UCC diagnosis and ED diagnosis. A total of 41% of patients underwent advanced imaging studies, 26% received specialty consultations, and 15% were admitted. Subgroup analysis for lacerations, extremity/fracture care, and abnormal electrocardiograms (ECGs) showed disproportionally high levels of discordant diagnoses and referrals that did not require ED-specific care or resources. Our data found that 55% of patients referred to EDs from UCCs did not require ED-specific care or resources and 64% carried a discordant diagnosis between UC and ED diagnosis. We suggest quality remedies, such as educational sessions and engagement with telemedicine sub-specialists as well as a coordinated formalized system for UCC to ED referrals.

Adverse outcomes associated with recorded victimization in mental health electronic records during the first UK COVID-19 lockdown

PurposeThe impact of COVID-19 pandemic policies on vulnerable groups such as people with mental health problems who experience violence remains unknown. This study aimed to investigate the prevalence of victimization recorded in mental healthcare records during the first UK lockdown, and associations with subsequent adverse outcomes.MethodsUsing a large mental healthcare database, we identified all adult patients receiving services between 16.12.2019 and 15.06.2020 and extracted records of victimisation between 16.03.2020 and 15.06.2020 (first UK COVID-19 lockdown). We investigated adverse outcomes including acute care, emergency department referrals and all-cause mortality in the year following the lockdown (16.06.2020- 01.11.2021). Multivariable Cox regressions models were constructed, adjusting for socio-demographic, socioeconomic, clinical, and service use factors.ResultsOf 21,037 adults receiving mental healthcare over the observation period, 3,610 (17.2%) had victimisation mentioned between 16.03.2020 and 15.06.2020 (first UK COVID-19 lockdown). Service users with mentions of victimisation in their records had an elevated risk for all outcomes: acute care (adjusted HR: 2.1; 95%CI 1.9–2.3, p < 0.001), emergency department referrals (aHR: 2.0; 95%CI 1.8–2.2; p < 0.001), and all-cause mortality (aHR: 1.5; 95%CI 1.1–1.9; p = 0.003), when compared to service users with no recorded victimisation. We did not observe a statistically significant interaction with gender; however, after adjusting for possible confounders, men had slightly higher hazard ratios for all-cause mortality and emergency department referrals than women.ConclusionPatients with documented victimisation during the first UK lockdown were at increased risk for acute care, emergency department referrals and all-cause mortality. Further research is needed into mediating mechanisms.

Establishment and Utilization of an Advanced Practice Provider-Led Clinic for Newly Diagnosed Venous Thromboembolism

BACKGROUND: Evidence supports treating most patients with venous thromboembolism (VTE) as outpatients. There is hesitancy among some healthcare providers to manage patients with these high-risk acute conditions, on high-risk medications, without close and reliable follow-up. In the era of direct oral anticoagulants (DOACs), the financial complications associated with appropriate anticoagulation further complicate management. The benign hematology group at the University of North Carolina (UNC) at Chapel Hill developed an Advanced Practice Provider (APP)-led clinic to address this area of need, aiming to improve efficacy and safety in the outpatient setting for patients with acute VTE. METHODS: An APP-led acute VTE clinic, "Walk-In DVT Clinic", located within Benign Hematology was established with one appointment reserved each weekday. Patients with newly diagnosed VTE can be referred by any UNC-affiliated provider. A triage system with direct pager and phone line ("1-DVT") is available during business hours. For patients referred after-hours through the Emergency Department (ED), direct scheduling is available 24 hours/day. Patients are seen by the APP (physician assistant or nurse practitioner) with hematologist oversight. Pharmacist support is available for questions about drug interactions, medication access, and other needs. Patient education and counseling on diagnosis and anticoagulation is provided. Patients are evaluated for risk factors which contributed to the VTE, and follow-up for longer-term discussion of anticoagulation plans is scheduled. Following appointment, patients have access to nurse and provider assistance for bleeding complications, anticoagulation management for surgical/procedural planning, medication access, or other complications. Here we present demographics and referral data for patients seen in the first two years. RESULTS: Since initiation, a total of 234 patients have been seen, of which data was available for 229. Specifically, 84 in the first year (8/24/20 through 7/31/21) and 150 in the second year (8/1/21 through 7/31/22). Of these, 72% were ED referrals, and 12.7% required financial assistance of some kind. In the second year, 59.3% of referrals were ED, and 10% required medication assistance of some kind. Patient demographics are listed in the table below. In the second year, significant changes in medical plan (examples: dose errors, misdiagnosis) were identified in 19 cases (12.67%). The median time to appointment in the first year was 4 days and in the second year was 5 days (including weekend days). DISCUSSION: The "Walk-In DVT” clinic grew quickly in its first year and continued to grow in the second year, nearly doubling in utilization. In the first year, time-to-visit median was 4 days, and the program's aim was to decrease this. However, with increased utilization, this metric increased to 5 days. As a consequence, a second APP has been hired to improve access. The types of providers referring to the clinic diversified, with more referrals from surgical and medicine specialties and a lower overall percentage of ED follow-ups. This finding supports progress in one goal of the clinic, to have providers who diagnose a VTE refer directly to the DVT Walk-In Clinic rather than send them to the ED. Expanding the network of outpatient providers using the clinic is a future goal. The demographics of patients showed an increase in use by African American and Hispanic patients. Importantly, the increase in Hispanic patients has highlighted the need for better patient education materials translated to Spanish, prompting efforts to produce and translate new materials. In summary, since its inception, the APP-led "DVT Walk-In Clinic” has grown in utilization, diversity of referrals, and diversity of patients served, with new focus on patient education tools and expanding access. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 10411: Low Rate of Major Adverse Cardiovascular Events in Patients Presenting to Urgent Care With Chest Pain and a Moderate HEART Risk Score Who Were Referred for an Expedited Outpatient Cardiology Evaluation

Introduction: The HEART score is an effective method of risk stratifying emergency department (ED) patients with chest pain. The low rate of major adverse cardiovascular events (MACE) in patients with a moderate risk HEART score referred from an urgent care (UC) center for an expedited outpatient cardiology evaluation was first described by this group in 2020. This is a follow up study with a total of 446 patient over a 36 month period. Hypothesis: Patients with a moderate risk HEART score who present to the ED are usually hospitalized for further evaluation. The safety of outpatient evaluation of these patients is not well studied. We assessed the hypothesis that there is a low rate of MACE when patients with a moderate risk HEART score were referred from an UC for an expedited outpatient cardiology follow up. Methods: A cross sectional study was performed from 2/14/2019 through 3/30/2022 in 5 UC centers of 446 patients who presented with chest pain or anginal equivalent and a HEART score of 4 to 6 in Las Vegas, Nevada. A streamlined disposition protocol was adopted by all UC providers for an expedited outpatient cardiology instead of ED referral. The population was followed for 6 weeks with a primary endpoint of MACE (death, myocardial infarction (MI), revascularization) determined by electronic medical records review and direct phone contact with patients. Outcomes were confirmed in 93% of patients. Results: The average age was 65 years with 52% female and 48% male. 395 patients (89%) were seen by a cardiology provider, 346 patients (88%) were seen within 3 days. 265 stress tests (67%), 42 coronary CT angiograms (11%) and 19 invasive coronary angiograms (5%) were ordered. 8 patients (2%) were found to have MACE: 2 had routine surgical revascularization, 4 had non-fatal MI followed by revascularization, 2 patients died: 1 was urgently referred for mitral valve replacement and died after surgery from renal failure and COVID, the other patient died from COVID pneumonia. There were no ischemic cardiac deaths. Conclusion: In conclusion, patients with a moderate risk HEART score referred from UC for an expedited outpatient cardiology evaluation had a low rate of MACE and no ischemic cardiac deaths due to delay of care.

Factors related to substance use treatment attendance after peer recovery coach intervention in the emergency department

IntroductionBrief intervention with peer recovery coach support has been used to generate referrals to substance use disorder treatment from the emergency department (ED). This retrospective study evaluated factors associated with successful linkage to treatment following brief intervention in the ED. MethodsData were extracted from the electronic health record for patients who were referred to substance use treatment from the ED and for whom follow-up data regarding treatment attendance was available (n=666). We examined associations between demographic and insurance variables, substance use, mental health diagnosis, prior abstinence, and stage of change with successful linkage to substance use treatment after ED referral. ResultsThe sample was majority male (68%), White (62%), and had a mean age of 43 years (SD=12). Medicaid was the most common insurance (49%) followed by employer/private (34%). Multivariable logistic regression determined patients with Medicaid (OR=2.94, 95% CI:2.09-4.13, p=<.001), those who had a documented alcohol use disorder diagnosis (OR=1.59, 95% CI:1.074-2.342, p=.02), and those in the “Action” stage of change (OR=2.33, 95% CI:1.47-3.69, p=<.001) had greater odds of being successfully linked to treatment. ConclusionsThese results identify characteristics of patients available in the health record to determine who is more likely or less likely to attend substance use treatment following ED referral. Given appropriate screening, this information could be used to direct standard care resources to those with high likelihood of treatment attendance and strengthen follow-up interventions with peer recovery coaches for those with lower likelihood of treatment attendance.

Insights from and limitations of data linkage studies: analysis of short-stay urgent admission referral source from routinely collected Scottish data

IntroductionThis study identified the referral source for urgent short-stay admissions (SSAs) and compared characteristics of children with SSA stratified by different referral sources.MethodsRoutinely acquired data from urgent admissions to Scottish...

“Pseudo-Geyser Sign” as the First Presentation of Septic Arthritis of the Shoulder

Massive rotator cuff tears can lead to large cysts, extending from the subacromial space through the acromioclavicular joint into a subcutaneous cyst, with a typical “geyser sign” on magnetic resonance imaging (MRI). To our knowledge, no cases of transdeltoid pseudo-cyst as first manifestation of septic arthritis have ever been reported.A 79-year-old female presented to the Emergency Department (ED) with a two-day evolution of a painful tumefaction over her right shoulder. She had been admitted to the ED 16 days before, after being bitten by a dog. Tumefaction drainage revealed a total cell count of 50320 cells/mL. MRI revealed glenohumeral joint cavity’s fluid “decompression” through the deltoid. Septic arthritis was presumed as the cause of the pseudo-cyst, configuring a “pseudo-geyser sign” on MRI.Septic arthritis is an orthopedic emergency, whose early diagnosis, ED referral and treatment are crucial.

Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis

IntroductionWith the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic. MethodsChildren aged < 18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The “COVID” cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts. ResultsTwenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P < 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P < 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P < 0.001). ConclusionsTransferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability.

Screening for Child Abuse in Children With Isolated Skull Fractures.

Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF. A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma. To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.

819 Management of Maxillofacial Trauma Emergency Department Presentations in an Evolving Pandemic. Did COVID-19 Change Our Practice?

Abstract Aim Trauma encompasses a significant proportion of referrals to Oral Maxillofacial Surgery (OMFS). COVID-19 called for clinicians globally to tailor practice and follow-up patterns. Multiple government-imposed lock downs saw changes in patterns of emergency department (ED) attendances nationally. The aim of this audit was to examine the impact of COVID-19 on Maxillofacial trauma presentations, admissions, and existing practice in University Hospital of Wales (UHW). Method Data was collected using an electronic patient database “Team Talk”. Patients filtered by pathology (Soft tissue trauma, fractures) and location (ED). Annual data collected for 2019, 2020 and 2021, to compare pre-pandemic (2019), evolving pandemic (2020) and established pandemic (2021) figures. Results Trauma made up 74%, 73% and 78% of total OMFS referrals (2019, 2020, 2021). There was an 83% decrease in the number of trauma referrals between 2019 and 2020, despite UHW becoming a major trauma centre. No correlation identified between trauma presentations and lockdown events (2020) but lifting of restrictions (September 2021) showed an increase in presentations. 16.8%, 16.4% and 16.2% (2019, 2020 and 2021, respectively) of ED referrals were offered follow up follow up. Percentage of follow up appointments used for removal of sutures (ROS) decreased by 30% (2019–2020). Conclusions

Analysis of self-initiated visits for cervical trauma at urgent care centers and subsequent emergency department referral

BackgroundFollowing trauma involving the cervical spine (c-spine), patients often seek care at urgent care centers (UCCs) or emergency departments (EDs). PurposeThe purpose was to assess whether UCCs could effectively image acute self-selected c-spine trauma without referral to the ED as well as to estimate costs differences between UCC and ED imaging assessment. Materials and methodsThis retrospective study identified patients receiving c-spine imaging at UCCs affiliated with a large academic hospital system from 5/1/-8/31/2021. Patients receiving c-spine X-rays with an indication of trauma following low acuity injury, at UCCs were compared to patients receiving any c-spine imaging in the main campus ED. Medical record numbers were cross-referenced to identify patients receiving imaging at both a UCC and ED within 24 h and within 7 days. Work relative value units (wRVUs) for each UCC and ED imaging type were calculated. For the hypothetical scenario of patients presenting to the ED in the absence of UCC, patients were assumed to receive c-spine computed tomography (CT) without contrast per “usually appropriate” designation by the American College of Radiology Appropriateness Criteria®. ResultsAmong 143 self-selected, low acuity, patients who received c-spine X-rays at UCCs with an indication of trauma, one required referral to the ED within 24 h and two required referrals to the ED within 7 days. During the 4-month study period, 105.94 wRVUs ($3696.25) were saved by performing a c-spine X-ray in an UCC instead of a CT in the ED, extrapolated to 317.82 wRVUs ($11,088.74) per year. Using the average total costs of an UCC visit versus an ED visit, a total $145,976 was estimated to be saved during the study period or $437,928 per year. ConclusionOffering access for patient-initiated visits at UCCs for low-acuity c-spine trauma may help reduce the need for an ED visit, reducing imaging and healthcare visit costs. Summary statementUrgent Care Centers (UCCs) reduced the need for an Emergency Department (ED) referral visit in nearly 100% of self-selected, low acuity, patients with cervical trauma. Key results•Only 1.4% of patients required referral to an ED after a UCC visit for acute cervical trauma in this specific population.•In our system, UCCs are estimated to result in a savings of $437,928 over the course of a year in reduced ED visit costs, and $11,088.74 in wRVUs for this specific population.