Regional Emergency Department Research Articles

Twelve-year review of horse-related trauma registry presentations to a regional Australian Emergency Department.

The size, strength, and unpredictability of horses, makes any interaction a potential situation for minor to severe injury. Despite this, horses continue to be popular for work and recreational activities. There have been five recent Australian publications that have examined various aspects of horse-related trauma, but none have been conducted in regional New South Wales (NSW). This study aims to report on the pattern of horse-related trauma that met the Institute of Trauma Injury Management's (ITIM) Trauma Registry criteria for people who presented to the emergency department at a regional NSW hospital, Australia. An analysis of horse-related trauma extracted from the Wagga Wagga Base Hospital's Trauma Registry from 2012 to 2023 was undertaken. Demographic and clinical variables were reported on all people (n = 85) and statistically evaluated. The cohort median age was 46 years (range 2-78). Males represented 51.8%. Fall from mounted position was the most common mechanism of injury (84.7%) followed by kick while unmounted (11.7%). The head (45.9%) and chest (32.9%) were the most common regions of injury with head (45.9%) and fractures (44.7%) the most common types of injury. 11.8% of people required ICU admission. Horse-related trauma, whether a person is mounted or unmounted, causes mild to severe injuries and can require hospitalization. Horse-related trauma has the potential to significantly impact morbidity, result in death and must not be underestimated. Establishing a protocol for horse-related trauma presentations and increasing awareness of injury patterns sustained from this mechanism has the potential to improve diagnosis and reduce morbidity.

Evaluation of nurse practitioners' extended scope of practice in a regional hospital emergency department in tropical Australia.

There is very little literature examining the workload and impact of nurse practitioners (NPs) working in emergency departments (ED) in regional and rural Australia. The aim of this paper was to review the ED NPs scope of practice in the ED discharge stream and patient outcomes at Cairns Hospital over a 7-month period. This retrospective study examined the ED electronic medical record between 14 May 2019 and 31 December 2019. Cases managed by ED NPs, referrals, procedures performed, representations and disposition data were collected. Adverse events were sought from the Qld Health adverse events register (Riskman), the department complaints register and the ED M&M meeting minutes. A total of 1443 patients were treated by NPs, with ages ranging from 0 to 98 years (median 40 years). Australasian Triage Score (ATS) 3 cases made up 30% of the workload. Other than ATS 3 cases, time to being seen was better than the general department. There were very few unexpected representations, complaints or adverse events. This study supports the view that NPs working in a regional emergency department can safely manage a variety of patients outside a fast-track model, with a wide age range and a variety of triage categories and diagnoses. We believe this has important implications for the provision of emergency care, especially in regional and rural Australia.

Mapping the patient journey: utilizing clinical informatics for a conceptual approach to identify aspects of emergency department access block

BackgroundThe study aims to map the patient journey in a regional Emergency Department (ED), identify factors causing extended Length of Stay (LOS) in ED during pre-COVID (2016–2019), COVID (2020–2022) and post-COVID (2023), and analyse the patient journey using clinical informatics. Through systematic analysis and root cause identification, the study seeks to establish a learning health system. This system will enhance patient experiences and improve timely and effective care delivery.MethodsSummarized data on ED presentations data were sourced from January 2016 to August 2023 for a 294-bed regional hospital in New South Wales (NSW). The patient’s journey from ED to admission inpatient wards was analysed using clinical informatics. The time spent in each segment of the ED journey was analysed separately and subdivided by specialty for further analysis.ResultsPatient characteristics remained similar year on year. The average ED LOS increased from 5.59 h during the pre-COVID period (2016–2019) to 8.48 h during the COVID period (2020–2022) and 8.52 h during the post-COVID period (2023). The hospital’s bed occupancy rate remained consistent before and during the COVID-19 pandemic, with a slight improvement afterwards, except for a decrease in 2020. The occupancy rate for ED-accessible beds during the pre-COVID period is higher than during the COVID and post-COVID periods. The admission from ED to Inpatient wards decreased from 35% pre-COVID to 28% during COVID. Of the total LOS, the ‘Bed Request’ to ‘Bed Ready’ time segment increased from 11.41% in 2016 to 41.19% in 2022. The admission of medical specialty consistently made up most admissions (32%) which increased during the COVID. The medical specialty also spent the most time in the ED, peaking at 880 min in 2022.ConclusionClinical Informatics is an effective tool to visualise the bottlenecks in clinical workflows. The ‘Bed Request’ to ‘Bed Ready’ time segment was the largest contributor to ED LOS and may have been attributed to a lack of bed availability. Patients took an average of 50 min to be transferred to Inpatient wards upon admission. Future studies could utilize insights gained to develop specific key performance indicators aimed at improving ED LOS. Moreover, we are currently working on improving real-time access to inpatient beds but are currently hampered by the ‘manual update’ of bed status that is controlled by the individual wards. We aim to build an automated system that can monitor and update bed availability (e.g., patient discharge) with minimal human intervention.

Pathology requesting in a regional Australian Emergency Department; an observational study comparing current practice with college guidelines.

In 2018, the Australasian College for Emergency Medicine (ACEM) and the Royal College of Pathologists of Australasia (RCPA) produced a guideline to encourage appropriate pathology requesting in the Emergency Department (ED). To assess adherence to the ACEM/RCPA pathology testing guideline in a regional ED. This was a retrospective observational study conducted at a regional Australian ED over 7 days. Adults with a presenting complaint encompassed by the guideline were included. All blood tests were audited against the guideline recommendations and classified as indicated or non-indicated. Chi-squared analyses were performed to explore the association between presenting complaint and non-indicated testing. The primary outcome was the number of non-indicated blood tests. Forty percent of tests ordered were not clinically indicated, with non-indicated testing occurring during 87% of encounters. The C-reactive protein (CRP) was the test most frequently ordered outside of guidelines (94% non-indicated). Patients presenting with lower abdominal pain accounted for nearly one-quarter of all non-indicated tests. Blood tests were commonly requested outside of the guideline recommendations and interventions to improve pathology stewardship are required.

Data-Driven Implementation Strategy to Optimise Clinician Behaviour Change at Scale in Complex Clinical Environments: A Multicentre Emergency Care Study.

To develop an evidence-driven, behaviour change focused strategy to maximise implementation and uptake of HIRAID (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) in 30 Australian rural, regional and metropolitan emergency departments. An embedded, mixed-methods study. This study is the first phase of a step-wedge cluster randomised control trial of HIRAID involving over 1300 emergency nurses. Concurrent quantitative and qualitative data were collected via an electronic survey sent to all nurses to identify preliminary barriers and enablers to HIRAID implementation. The survey was informed by the Theoretical Domains Framework, which is a synthesis of behavioural change theories that applies the science of intervention implementation in health care to effect change. Quantitative data were analysed using descriptive statistics and qualitative data with inductive content analysis. Data were then integrated to generate barriers and enablers to HIRAID implementation which were mapped to the Theoretical Domains Framework. Corresponding intervention functions and Behaviour Change techniques were selected and an overarching implementation strategy was developed through stakeholder consultation and application of the APEASE criteria (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety and Equity). Six barriers to HIRAID implementation were identified by 670 respondents (response rate ~58%) representing all 30 sites: (i) lack of knowledge about HIRAID; (ii) high workload, (iii) lack of belief anything would change; (iv) not suitable for workplace; (v), uncertainty about what to do and (vi) lack of support or time for education. The three enablers were as follows: (i) willingness to learn and adopt something new; (ii) recognition of the need for something new and (iii) wanting to do what is best for patient care. The 10 corresponding domains were mapped to seven intervention functions, 21 behaviour change techniques and 45 mechanisms. The major components of the implementation strategy were a scaffolded education programme, clinical support and environmental modifications. A systematic process guided by the behaviour change wheel resulted in the generation of a multifaceted implementation strategy to implement HIRAID across rural, regional and metropolitan emergency departments. Implementation fidelity, reach and impact now require evaluation. HIRAID emergency nursing assessment framework reduced clinical deterioration relating to emergency care and improved self-confidence and documentation in emergency departments in pilot studies. Successful implementation of any intervention in the emergency department is notoriously difficult due to workload unpredictability, the undifferentiated nature of patients and high staff turnover. Key barriers and enablers were identified, and a successful implementation strategy was developed. This study uses theoretical frameworks to identify barriers and enablers to develop a data-driven, behavioural-focused implementation strategy to optimise the uptake of HIRAID in geographically diverse emergency departments which can be used to inform future implementation efforts involving emergency nurses. The CROSS reporting method (Supporting Information S3) was used to adhere to EQUATOR guidelines. No Patient or Public Contribution. Australian New Zealand; Clinical Trials Registry (ANZCTR) number: ACTRN12621001456842, registered 25/10/2021.

Establishing enablers and barriers to implementing the HIRAID® emergency nursing framework in rural emergency departments

BackgroundRural Australia has large geographic distances between emergency departments with variability of services and medical support. Emergency nurses must be appropriately skilled to assess and manage unpredictable and diverse presentations. HIRAID® is an evidence-based framework to support emergency nurses in assessment and care delivery. To inform implementation, the study aimed to identify the enablers and barriers to introducing HIRAID® in practice. MethodsThis embedded mixed methods study was conducted in 11 rural, regional emergency departments in Southern New South Wales, Australia. Respondents completed a 22-item survey, indicating their level of agreement on statements related to practice change, free text responses were optional. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Results were identified as barriers or enablers, then integrated and mapped to the Theoretical Domains Framework. ResultsThe survey was completed by 102 (54 %) nurses. Two enablers and four barriers to implementation were identified and mapped to 10 Theoretical Domains Framework domains. Key barriers were workplace limitations, such as time and resources, and knowledge of the HIRAID® intervention. ConclusionBarriers varied between facilities related to adequate support to implement and the impact on patient care. The results will inform a strategy to implement HIRAID®.

Reshaping Emergency Care: Dynamics of OHCA and STEMI in a Three-Year Analysis.

The COVID-19 pandemic drastically reshaped healthcare in Lombardy, Italy, notably impacting EMS and emergency departments and altering the epidemiology of time-dependent pathologies such as STEMI and OHCA. While previous studies focused on modifications during the pandemic peak, with an increase in the number of OHCA diagnoses and a reduction in the number of STEMI, little evidence exists regarding the inter-pandemic phases. We analyzed OHCA and STEMI accesses to the ED in the regional emergency department access register (EUOL) for 2019-2021. The analysis revealed a significant difference in monthly diagnosis averages. For STEMI, the change was statistically significant (F(2, 33) = 4.45, p = 0.02), while it was not for OHCA (F(2, 33) = 0.18, p = 0.83). Despite the monthly decreases, the likelihood of receiving a STEMI diagnosis increased with total accesses, OR 1.40 [95% CI 1.25-1.58, p < 0.0001]. Additionally, there was a significant increase in March 2020 discharge diagnoses for OHCA compared to March 2019, OR 3.35 [95% CI 2.88-3.90, p < 0.0001], corresponding to the first pandemic wave. Therefore, our analysis indicates that the epidemiology of STEMI and OHCA was altered during the COVID-19 pandemic.

Time to ECG diagnosis delays inter-hospital transfer to revascularization in STEMI patients presenting to a regional emergency department: a five-year audit

BackgroundReducing the door-to-balloon time (D2BT) in ST-elevation myocardial infarction (STEMI) patients maximizes myocardial salvage and mitigates morbidity/mortality.AimsTo assess the D2BT in STEMI patients requiring inter-hospital transfer for revascularization and identify any potential causes of delay.MethodsConsecutive patients presenting to the Connolly Hospital Blanchardstown (CHB) emergency department (ED) who were transferred to the Mater Misericordiae University Hospital in Dublin for primary percutaneous coronary intervention from January 2018 to October 2022 were identified in a regional database and their D2BTs calculated. D2BTs were further sub-categorized into key intervals to identify any potential causes of delay.ResultsA total of 90 patients were included for analysis, with a median D2BT of 117.5 min (interquartile range [IQR]: 99.3–170.8 min) and 52.5% of patients achieving the ≤ 120 min target. Despite being the shortest interval considered, the time from arrival at the CHB ED to diagnostic electrocardiogram (ECG) was a substantial contributor to the overall delay to revascularization given its wide variability (median: 18.0 min; IQR: 9.0–46.8 min), with only 28.8% of patients achieving the ≤ 10 min target.ConclusionsNearly half of the patients studied failed to achieve the overall target D2BT for revascularization. The time from arrival at the CHB ED to diagnostic ECG was identified as a substantial contributor to this failure, with a median time almost twice that of the target and a quarter of all patients spending longer than 46.8 min. These findings highlight a need to improve the implementation of ECG triage and interpretation in the ED.

Designing a standardised emergency nurse career pathway for use across rural, regional and metropolitan New South Wales, Australia: A consensus process

BackgroundEmergency nurses are the first clinicians to see patients in the ED; their practice is fundamental to patient safety. To reduce clinical variation and increase the safety and quality of emergency nursing care, we developed a standardised consensus-based emergency nurse career pathway for use across Australian rural, regional, and metropolitan New South Wales (NSW) emergency departments. MethodsAn analysis of career pathways from six health services, the College for Emergency Nursing Australasia, and NSW Ministry of Health was conducted. Using a consensus process, a 15-member expert panel developed the pathway and determined the education needs for pathway progression over six face-to-face meetings from May to August 2023. ResultsAn eight-step pathway outlining nurse progression through models of care related to different ED clinical areas with a minimum 172 h protected face-to-face and 8 h online education is required to progress from novice to expert. Progression corresponds with increasing levels of complexity, decision making and clinical skills, aligned with Benner’s novice to expert theory. ConclusionA standardised career pathway with minimum 180 h would enable a consistent approach to emergency nursing training and enable nurses to work to their full scope of practice. This will facilitate transferability of emergency nursing skills across jurisdictions.

COVID-19, Influenza, and RSV in Children and Adults: A Clinical Comparative Study of 12,000 Cases.

(1) Background: Respiratory virus infections, including Coronavirus disease 2019 (COVID-19), seasonal influenza (FLU), and respiratory syncytial virus (RSV) as prominent examples, can severely affect both children and adults. This study aimed to investigate the clinical characteristics of respiratory viral infections in pediatric and adult populations and to identify determinants influencing patient hospitalization. (2) Methods: This retrospective study analyzed the electronic medical records of patients admitted to a regional hospital's emergency department from 1 January 2015 to 31 December 2022, to investigate the clinical characteristics and hospitalization risk factors associated with these three viruses. (3) Results: Infants aged 1 to 11 months were most affected by COVID-19 and RSV, whereas FLU more commonly infected children aged 3 to 5 years. Key factors influencing hospitalization included age and abnormal chest X-ray findings, with higher risks observed in younger children and adults over 65. Notably, the presence of abnormal chest x-ray findings significantly increased the hospitalization risk by 1.9 times [1.5-2.4] in children and 21.4 times [2.4-189.0] in adults. (4) Conclusions: This analysis underscores the impact of COVID-19, FLU, and RSV on hospitalization risk, offering insights for managing these respiratory viral infections (RVIs). Age-related risk differences highlight the necessity for tailored strategies, improving understanding of and treatment development for RVIs.

Combined Hepatitis B Virus and Hepatocellular Carcinoma Screening Using Point-of-Care Testing and Ultrasound in a Tanzanian Emergency Department.

The WHO aims to detect 90% of global cases of hepatitis B virus (HBV) by 2030. Sub-Saharan Africa carries a disproportionate burden of HBV and hepatocellular carcinoma (HCC). In this study, we sought to assess the utility of a combined HBV and HCC screening program in Tanzania. We conducted a prospective, serial cross-sectional study of patients who participated in a combined HBV and HCC screening program at a regional referral hospital emergency department (ED) in Arusha, Tanzania, between April 19, 2022 and June 3, 2022. All patients completed a study questionnaire and were tested for HBV surface antigen. Patients who were HBV positive were screened for HCC via point-of-care ultrasound (POCUS). The primary outcome was the number of new HBV diagnoses. Data were analyzed with descriptive statistics. A total of 846 patients were tested for HBV (primary ED: 761, clinic referral: 85). The median age of patients was 44 ± 15 years, and 66% were female. Only 15% of patients reported having a primary care doctor. Thirteen percent of patients had been previously vaccinated for HBV. There were 17 new HBV diagnoses (primary ED: 16, clinic referral: 1), which corresponds to a seroprevalence of 2.0% (95% CI: 1.2%, 3.2%). No patients had liver masses detected on POCUS. An ED-based, combined HBV and HCC screening protocol can be feasibly implemented. This study could serve as a model for HBV/HCC screening in regions with high HBV endemicity and low rates of community screening.

Examining food insecurity in a regional New Zealand emergency department: A cross-sectional study.

To determine the prevalence of food insecurity (FI) among patients in a regional New Zealand ED, factors associated with FI and feasibility of an ED-based FI screening programme with voluntary social work (SW) follow up. Cross-sectional study of patients presenting to the Whangarei Hospital ED, using the validated two-item Hunger Vital Sign screening tool to assess for FI. Participants were offered SW follow up to discuss community food resources. Of the 300 participants who completed the questionnaire, 111 (37.0%, 95% confidence interval [CI] 32.0-43.0) were food insecure. Factors associated with FI include Māori ethnicity (odds ratio [OR] 2.12 [95% CI 1.19-3.80], P = 0.011), household crowding (OR 1.19 [95% CI 1.02-1.39], P = 0.024) and lower socioeconomic status (OR 1.13 [95% CI 1.00-1.27], P = 0.048). There was no statistically significant association between FI and number of comorbidities or the primary reason for ED attendance. Of participants who were food insecure, only half reported being aware of (n = 56/111, 50.5%) or had used (n = 60/111, 54.1%) food resources. Participants who were food insecure were more likely to have utilised resources, either currently or in the past (OR 8.50 [95% CI 4.46-16.18], P < 0.001). Forty (13.3%) participants requested SW follow up and of those, most (n = 31/40, 77.5%) were successfully contacted. FI was associated with interest in SW follow up (OR 16.95 [95% CI 5.81-49.42], P < 0.001). At follow up, the majority (n = 24/31, 77.4%) of participants requested further information regarding food resources. FI was prevalent among patients in a regional NZ ED. An ED-based FI screening programme with voluntary SW follow up was feasible and acceptable to ED patients.

Analysis of Violent Incidents at Five Regional and Remote Australian Emergency Departments: A Retrospective Descriptive Study.

Workplace violence is endemic, destructive, and escalating in frequency and severity in healthcare. There is a paucity of research on workplace violence in regional and remote hospital emergency departments (EDs). The aim of this study was to identify the perpetrator and situational characteristics associated with violent incidents in the ED across five regional and remote Australian sites. This study audited hospital summary data, incident reports, and medical records for a 12-month period in 2018 to examine the perpetrator and situational characteristics of workplace violence incidents in five regional and remote Australian EDs. Violent incidents were evenly spread throughout the week and across shifts. Most incidents were triaged as urgent, occurred within the first 4 hr, and had multidisciplinary involvement. Almost one in every six incidents resulted in an injury. Perpetrators of violence were predominantly young and middle-aged males and almost always patients, with most presenting with mental and behavioral disorders, or psychoactive substance use. Understanding the characteristics of perpetrators of violence can help in seeking to tailor interventions to reduce further violent behaviors. These findings carry implications for optimizing patient care, staff safety and resource management.

162 A National Emergency Department Registry for Mpox

162 A National Emergency Department Registry for Mpox

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study

IntroductionAirway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. MethodsThe National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. ResultsOf 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1–2.5, range 1–31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. ConclusionsEGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

The impact of low socioeconomic statusand primary health care access on emergency department presentations in young children in regional Queensland.

The purpose of this study was to empirically evaluate if children from low socio-economic status (SES) families in regional southeast Queensland utilise acute care services for low acuity health care rather than utilising primary health services. A retrospective audit of children under the age of 5 years presented at a regional hospital emergency department (ED) over a 12-month period. Medical records were examined for presenting problem, Australasian triage category, care outcomes, whether the child's parent/guardian held an Australian concession/health care card (AC/HCC) and accessed child health services or a general medical practitioner (GP). Eight hundred and eighty-eight children who had not reached their fifth birthday presented to ED between 1 June 2019 and 31 May 2020, with a total of 1691 presentations. Most children were bought to the ED by their parents with semi-urgent health concerns and were discharged home following medical review. Holding an AC/HCC was a significant predictor for hospital presentation. Holding an AC/HCC was not associated with access to child health services. However, accessing child health services resulted in a small but significant increase in hospital presentations. The AC/HCC may be an important proxy to identify low SES individuals. These card holders tended to use acute services more frequently than those who did not qualify for an AC/HCC. Furthermore, families that engage with primary care services such as child health also accessed acute care services more frequently. The results indicate accessing primary health-care services does not ameliorate the use of acute care services.

How Tasmanian Emergency Departments 'Choose Wisely' When Investigating Suspected Pulmonary Embolism.

Overuse of computed tomography pulmonary angiograms (CTPAs) for diagnosis of pulmonary embolism (PE) has been recognised as an issue for over ten years, with Choosing Wisely Australia recommending that CTPAs only be ordered if indicated by a clinical practice guideline (CPG). This study aimed to explore the use of evidence-based practice within regional Tasmanian emergency departments in relation to CTPA orders by determining whether CTPAs were ordered in accordance with validated CPGs. We conducted a retrospective medical record review of all patients who underwent CTPA across all public emergency departments in Tasmania between 1 August 2018 and 31 December 2019 inclusive. Data from 2758 CTPAs across four emergency departments were included. PE was reported in 343 (12.4%) of CTPAs conducted, with yield ranging from 8.2% to 16.1% between the four sites. Overall, 52.1% of participants had neither a CPG documented, nor a D-dimer conducted before their scan. A CPG was documented before 11.8% of scans, while D-dimer was conducted before 43% of CTPAs. The findings presented in this study indicate that Tasmanian emergency departments are not consistently 'Choosing Wisely' when investigating PE. Further research is required to identify explanations for these findings.

Epilepsia Partialis Continua Presenting as Hypoxemic Respiratory Failure (P9-1.004)

<h3>Objective:</h3> An unusual case of a patient with epilepsia partialis continua (EPC) who presented with abdominal spasm and hypoxemic respiratory failure necessitating intubation. <h3>Background:</h3> EPC, also known as focal motor status epilepticus, is a is a rare, recurrent, focal seizure disorder that has a wide range of clinical presentation. EPC usually manifests with treatment-resistant seizures with retained awareness and unilateral motor symptoms. The differential diagnosis of the underlying causes of EPC is broad, including structural etiologies such as malignancy, focal cortical dysplasia, and ischemic stroke, and metabolic disorders such as non-ketotic hyperglycemia. <h3>Design/Methods:</h3> <h3>Case Presentation:</h3> Our patient is a 23-year-old woman with a history of a steroid responsive encephalitis complicated by focal aware and focal impaired awareness seizures as well as psychogenic non-epileptic seizures. She presented to a regional emergency department three times over a 48 hours period for episodes of abdominal spasms that spread through all of her limbs equally and occurred very briefly every two to three minutes. She was told each time that her episodes were nonepileptic. <h3>Results:</h3> Upon transfer to our center, she continued to have frequent episodes of diaphragmatic spasm without EEG correlate until she developed respiratory failure and altered mental status. She was intubated and placed on continuous EEG. After a paralytic trial, she was found to have focal electrographic seizures with bilateral (left &gt; right) parasaggital, sharp rhythmic, alpha activity evolving to theta activity. <h3>Conclusions:</h3> EPC is frequently silent on EEG. This patient had a rare form of abdominal and diaphragmatic epilepsy with preserved awareness that ultimately progressed to respiratory failure. The ictal nature of her symptoms only became apparent on EEG after administration of paralytics. In patients with abdominal spasm, it is important to consider ictal causes that may not be electrographically evident. <b>Disclosure:</b> Dr. O’Connor has nothing to disclose. Dr. Stulberg has nothing to disclose. Dr. Johnson has nothing to disclose. The institution of Dr. Peters has received research support from NIH.

Estimated reimbursement impact of COVID-19 on emergency physicians.

The delivery and financing of health care services were altered in unprecedented ways by COVID-19 and subsequent policy responses. We estimated reimbursement losses to emergency physicians in 2020 compared to 2019 related to shifting acute care utilization during COVID-19. This was an observational analysis of the Clinical Emergency Department Registry (CEDR) and the Nationwide Emergency Department Sample (NEDS). Study sample included all ED visits from a sample of 214 emergency department (ED) sites in the CEDR in 2019 and 2020 as well as all ED visits in the NEDS in 2019. We identified level of service billing code for evaluation and management (E&M) services, insurance payer, and geographic location of ED visits across sites in the CEDR and linked these to fee schedules to estimate total professional reimbursement across sites. Our primary analysis was to estimate reimbursement in 2020 compared to 2019 across the CEDR sites. In our secondary analysis, we linked sites in the CEDR to those in NEDS to estimate nationwide reimbursement. Total E&M reimbursement for emergency physicians in the CEDR was $1.6 billion in 2019 and $1.3 billion in 2020, reflecting a 19.7% decline year over year ($308 million loss). In our secondary analysis, we estimate nationwide losses of $6.6 billion, a -19.4% decline year over year. If emergency physicians had received maximum allowable federal relief funds via CARES Act Phases 1 to 3 (2% of 2019 revenue) this would sum to $680 million (2% of the $34 billion) or 10.3% of the estimated $6.6 billion pandemic-related losses. Our analyses provide an estimate of the scale of economic impacts of the COVID-19 pandemic. These findings warrant consideration for policymaker relief and future redesign of emergency care financing. Ultimately, the COVID-19 pandemic likely expanded known cracks in the financing of health care into steep fault lines.

Operation of national coordinating service for interhospital transfer from emergency departments: experience and implications from Korea

BackgroundSince 2014, Korea has been operating the National Emergency Medical Situation Room (NEMSR) to provide regional emergency departments (EDs) with coordination services for the interhospital transfer of critically ill patients. The present study aimed to describe the NEMSR’s experience and interhospital transfer pattern from EDs nationwide, and investigate the factors related to delayed transfers or transfers that could not be arranged by the NEMSR.MethodsThis study was a retrospective cross-sectional analysis of the NEMSR’s coordination registry from 2017 to 2019. The demographic and hospital characteristics related to emergency transfers were analyzed with hierarchical logistic models.ResultsThe NEMSR received a total of 14,003 requests for the arrangement of the interhospital transfers of critically ill patients from 2017 to 2019. Of 10,222 requests included in the analysis, 8297 (81.17%) successful transfers were coordinated by the NEMSR. Transfers were requested mainly due to a shortage of medical staff (59.79%) and ICU beds (30.80%). Delayed transfers were significantly associated with insufficient hospital resources. The larger the bed capacity of the sending hospital, the more difficult it was to coordinate the transfer (odds ratio [OR] for transfer not arranged = 2.04; 95% confidence interval [CI]: 1.48–2.82, ≥ 1000 beds vs. < 300 beds) and the longer the transfer was delayed (OR for delays of more than 44 minutes = 2.08; 95% CI: 1.57–2.76, ≥ 1000 beds vs. < 300 beds).ConclusionsThe operation of the NEMSR has clinical importance in that it could efficiently coordinate interhospital transfers through a protocolized process and resource information system. The coordination role is significant as information technology in emergency care develops while regional gaps in the distribution of medical resources widen.