Regional Emergency Department Research Articles

Not All STEMI Patients Receive Timely Reperfusion: Considerations for Rural Emergency Departments.

Early reperfusion for ST-elevation myocardial infarction (STEMI) is well known to improve patient outcomes. A review of patient records in one rural health service in New South Wales, Australia, suggested that not all STEMI patients were receiving timely reperfusion. Consequently, the aim of this study was to further investigate factors influencing clinical decision making by primary care providers in relation to rural STEMI patients. This cross-sectional observational study was in two phases, a retrospective audit of patient records and a survey of rural general practitioners (GPs). In the first phase, patients with STEMI who were referred from small rural hospitals to a regional hospital emergency department (ED) were identified through the local health district database. In phase two, information from the database informed questions for a survey distributed to the GP visiting medical officers (VMOs) at small rural hospitals in the region. The survey was designed to ascertain factors that may contribute to delays in the care of STEMI patients. Of the STEMI patients identified (n = 139), 15% (21) who were eligible for medical reperfusion were not administered thrombolysis within 4 hours of triage. Auditing of this group's records found that ECGs were inaccurately interpreted for 76% of the missed STEMI patients. In the survey, about 55% of the GP respondents said they “very much agree” with the statement that they felt competent in STEMI management. Only 64% of the GP VMOs agreed they felt competent in diagnosis and management of a failed thrombolysis and not all respondents were aware of the relevant clinical guideline. Patients with missed STEMI are at higher risk of morbidity and mortality and increased length of stay, adding burden to the patient, carer and health service. Without addressing gaps in service provision and better adherence to clinical guidelines, unacceptable delays in STEMI management in rural health services are likely to continue.

A multicenter study of short-term changes in mental health emergency services use during lockdown in Kitchener-Waterloo, Ontario during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic and subsequent lockdown measures have led to increasing mental health concerns in the general population. We aimed to assess the short-term impact of the pandemic lockdown on mental health emergency services use in the Kitchener-Waterloo region of Ontario, Canada.MethodsWe conducted an observational study during the 6-month period between March 5 and September 5, 2020 using National Ambulatory Care Reporting System metadata from mental health visits to three regional Emergency Departments (ED); mental health and substance related police calls; and calls to a regional mental health crisis telephone line, comparing volumes during the pandemic lockdown with the same period in 2019. Quasi-Poisson regressions were used to determine significant differences between numbers of each visit or call type during the lockdown period versus the previous year. Significant changes in ED visits, mental health diagnoses, police responses, and calls to the crisis line from March 5 to September 5, 2020 were examined using changepoint analyses.ResultsInvoluntary admissions, substance related visits, mood related visits, situational crisis visits, and self-harm related mental health visits to the EDs were significantly reduced during the lockdown period compared to the year before. Psychosis-related and alcohol-related visits were not significantly reduced. Among police calls, suicide attempts were significantly decreased during the period of lockdown, but intoxication, assault, and domestic disputes were not significantly different. Mental health crisis telephone calls were significantly decreased during the lockdown period. There was a significant increase in weekly mental health diagnoses starting in the week of July 12 – July 18. There was a significant increase in crisis calls starting in the week of May 31 – June 6, the same week that many guidelines, such as gathering restrictions, were eased. There was a significant increase in weekly police responses starting in the week of June 14 – June 20.ConclusionsContrary to our hypothesis, the decrease in most types of mental health ED visits, mental health and substance-related police calls, and mental health crisis calls largely mirrored the overall decline in emergency services usage during the lockdown period. This finding is unexpected in the context of increased attention to acutely deteriorating mental health during the COVID-19 pandemic.

Validity and reliability of the Interagency Integrated Triage Tool in a regional emergency department in Papua New Guinea.

The Interagency Integrated Triage Tool (IITT) is a novel, three-tier triage system recommended by the World Health Organization. The present study sought to assess the validity and reliability of a pilot version of the tool in a resource-limited ED in regional Papua New Guinea. This pragmatic prospective observational study, conducted at Mount Hagen Provincial Hospital, commenced 1 month after IITT implementation. The facility did not have a pre-existing triage system. All ED patients presenting within a 5-month period were included. The primary outcome was sensitivity for the detection of time-critical illness, defined by 10 pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced external triage officer. There were 9437 presentations during the study period and 9175 (97.2%) had a triage category recorded. Overall, 138 (1.5%) were classified as category 1 (emergency), 1438 (15.7%) as category 2 (priority) and 7599 (82.8%) as category 3 (non-urgent). When applied by a mix of community health workers, nurses, health extension officers and doctors, the tool's sensitivity for the detection of time-critical illness was 77.8% (95% confidence interval 64.4-88.0). The admission rate was 14.5% (20/138) among emergency patients, 12.0% (173/1438) among priority patients and 0.4% (30/7599) among non-urgent patients (P=0.00). Death in the ED occurred in 13 (9.4%) of 138 emergency patients, 34 (2.4%) of 1438 priority patients and four (0.1%) of 7599 non-urgent patients (P=0.00). The negative predictive value for these outcomes was >99.5%. Among 170 observed triage assessments, weighted κ was 0.81 (excellent agreement). On average, it took clinicians 2min 43 s (standard deviation 1:10) to complete a triage assessment. There is limited published data regarding the predictive validity and inter-rater reliability of the IITT. In this pragmatic study, the pilot version of the tool demonstrated adequate performance. Evaluation in other emergency care settings is recommended.

162 Regional Emergency Department Census Impacts During a Cyber Attack

Modern emergency department (ED) care is critically dependent on computerized systems such as medical devices, electronic health records, and imaging systems. Many clinical systems have software and hardware vulnerabilities that can be exploited by malicious computer hackers. Cyber-attacks including ransomware on healthcare delivery organizations (HDO) are increasing in severity and frequency, impacting both individual hospitals and the broader regional healthcare delivery ecosystem. The effects of healthcare cyber-attacks on neighboring HDOs has yet to be reported in the literature. The purpose of this study is to report the impact on fully functioning hospital EDs during an active cyber-attack on a neighboring HDO. We performed a retrospective analysis of the daily combined census of two large urban academic EDs in San Diego, CA for the first week of a ransomware cyber-attack on a nearby multi-hospital HDO (May 2nd - 8th 2021). We then compared the mean to the 5-year historical census (2016-2020), matched by week (ex. first full week in May 2020 etc.) A one-way analysis of variance (ANOVA) and Tukey test were used to compare census years. The matched mean combined daily ED census for years 2016 - 2020 (no cyber-attack) were: 2016 – 221 (SD 12), 2017 – 211 (SD 21), 2018 – 174 (SD 30), 2019 – 229 (SD 29), and 2020 – 179 (SD17). For 2021 (week of the cyber-attack) the mean was 281 (SD 37). There was a statistically significant higher census during the cyber attack when compared to the 5 years prior (Table 1). Cyber attacks on hospitals can have significantly detrimental effects on patient care due to the loss of critical digital systems. This study demonstrated an associated “spill over” effect of significantly higher ED census numbers at facilities in proximity to HDOs under active cyber-attack.

Safety Planning for Youth With Suicide Risk: A Clinical Audit

ABSTRACT This quality improvement activity examined Safety Planning Intervention (SPI) over two 3-monthly periods for presentations from 13–17-year-olds with suicidal risk to a regional hospital Emergency Department (ED). We collected patient demography, presentation characteristics, presentation rate, and clinician use of SPI, including those under Emergency Examination Authorities (EEAs). An education workshop was offered between the audits, aimed to increase clinician (social work, psychology, nursing, and psychiatry) knowledge of SPIs. The annual ED presentation rate for suicide risk for 15–17-year-olds was 1,520 per 100,000 persons. More presentations were female, non-Indigenous persons, and fewer than half presented voluntarily. Most presentations were for suicide attempt followed by suicide threat. In the first audit clinicians initiated SPIs in fewer than 50% of cases and completed SPIs in 15%. Whereas in the second audit where SPIs were initiated by clinicians in 69% of cases and fully completed in 49%, less than half the presentations with EEAs received a completed SPI. Indigenous persons, although a lower proportion of presentations, were overrepresented for the population. Following the education workshop, there was an improvement in SPI completion, reflecting the benefits of education and training to clinical staff. Lastly, this study highlights the benefit of conducting audits as quality improvement activities for patient care. IMPLICATIONS The international literature indicates an increase in child and youth suicide attempts. This increase requires preparedness from social workers and other clinicians (psychology, nursing, and psychiatry) who offer front-line healthcare for these presentations. Safety plans are best-practice and tailored strengths-based plans undertaken between a clinician and client so that the client feels confident knowing where to go and to whom to talk to avoid further suicide attempts. Social workers play an important role in undertaking safety plans with clients (especially those who are particularly vulnerable) in hospital and community settings to maximise client outcomes.

Impact on patient management of non-mydriatic fundus photography compared to direct ophthalmoscopy in a regional Australian emergency department.

To investigate the management impact of non-mydriatic fundus photography (NMFP) implementation for appropriate ED patients; compare the diagnostic accuracy of direct ophthalmoscopy (DO) and NMFP, and determine the prevalence of fundus pathology in a regional Australian ED. This before/after crossover study prospectively enrolled patients presenting with headache, neurological deficit, visual disturbance and/or hypertensive urgency. Patients received DO examination, then separate NMFP examination. Emergency clinicians (ECs) were surveyed on their patient management plans following both DO examination and NMFP imaging. Telemedicine review of NMFP images was performed by an ophthalmologist within 48 h, and any additional management changes were documented. The use of NMFP influenced changes in management in 52 (39%) of 133 enrolled patients (95% confidence interval 31-48%). Of these, 65% were escalations of management due to acute fundus pathology, while 35% were de-escalating changes following normal fundus findings. ECs diagnostic accuracy for acute fundus pathology improved from 0% to 29% sensitivity, and 59% to 84% specificity using DO and NMFP respectively, and telemedicine registrar review increased this to 50% sensitivity and 86% specificity. The period prevalence of acute fundus pathology was 10.5% (95% confidence interval 6-17%). The addition of NMFP images can significantly impact the management of ED patients requiring fundus examination, facilitating expedited and optimised patient care. NMFP improves ECs diagnostic acumen for fundus pathology over DO examination and telehealth specialist review is important for diagnostic accuracy. There is a clinically important prevalence of fundus pathology in this regional ED setting.

The use of point-of-care ultrasound in a regional emergency department in KwaZulu-Natal, South Africa.

BackgroundFormal ultrasonography has advanced to point-of-care ultrasound (POCUS) in the emergency department (ED) for the purpose of acute critical care. While POCUS application expands, little is known about POCUS utilisation in public hospital EDs. This study aimed to describe the use of POCUS in an ED in KwaZulu-Natal.MethodsA retrospective chart review study was conducted on all patients who had POCUS exams performed in the ED at the General Justice Gizenga Mpanza Regional Hospital from 01 September 2019 to 31 March 2020. A data collection tool was used to extract the required data from the Mindray M6 ultrasound machine. The data were processed using the Statistical Package for Social Sciences (SPSS version 26) and descriptive statistics were used to summarise the data.ResultsA total of 978 POCUS were performed on 784 patients. Point-of-care ultrasound was utilised more often for focused emergency echocardiography in resuscitation (n = 383) and extended focused assessment with sonography for trauma (n = 319). The findings were normal in 17% of exams, 31% were positive, 9% were unspecified and 43% of POCUS exams were inconclusive. Seven percent of POCUS exams were performed by accredited level 1 emergency POCUS providers and ultrasounds occurred more frequently during day-shift hours than after-hours.ConclusionPoint-of-care ultrasound core applications were utilised by ED doctors for various emergency care scenarios, mainly for trauma and cardiac assessments.

Prevalence of Hepatitis C Virus Infection Identified From Nontargeted Screening Among Adult Visitors in an Academic Appalachian Regional Emergency Department.

BackgroundWe describe the initial results of an adult academic emergency department (ED) nontargeted hepatitis C virus (HCV) screening program serving Appalachia, which is disproportionately affected by the opioid epidemic.MethodsThe study was a retrospective screening study of ED systematic, nontargeted, opt-out HCV testing outcomes from July 2018 through September 2020. Eligibility requirements for “nontargeted” HCV testing included age ≥18 years, verbally able to communicate, receiving bloodwork already as part of routine clinical care, and not opting out of testing. For eligible individuals who did not opt out of testing, an HCV antibody (Ab) test was performed. Reactive Ab tests were confirmed with reflexive HCV RNA testing. The primary study outcome was the characterization of HCV Ab and RNA prevalence.ResultsThere were 75 722 unique adult visitors during the period studied. Of these, 54 931 individuals were verbally engaged regarding testing and did not opt out. A total of 34 848 individuals received HCV Ab testing, with 3665 patients (10.5%) having reactive results. RNA confirmatory testing was reflexively performed in all Ab-positive patients, with 1601 (50.3%) positive. The majority of HCV Ab– and RNA-positive patients were young, born after 1965, and were more likely to be White, male, Medicaid insured, and report a history of injection drug use.ConclusionsED nontargeted, opt-out testing can identify a high prevalence of HCV infection among adult visitors. HCV infection was disproportionately high among younger, White individuals, likely reflecting the escalating syndemic of opioid injection and HCV transmission in Appalachia.

The patient journey map: Improving the emergency department communication experience for patients and their family and friends

The patient journey map: Improving the emergency department communication experience for patients and their family and friends. Stephanie VandenBerg, Heather Hair, Gillian Harvey, Eddy Lang, David Stringer Background: The 2013 Urban and Regional Emergency Department (ED) Patient Experience Report indicates that the most important factor influencing a patients’ ED experience is a combination of staff care and communication. Lack of communication in the emergency room experience can be addressed by design methods and processes. The Emergency Strategic Care NetworkTM assembled an interdisciplinary team of experts from various clinical, academic, and information design backgrounds to engage patients, families and providers to improve the ED intake experience. This innovative partnership resulted in the development of a graphic information system that directs, informs and educates patients in EDs in Alberta. Implementation: Using the Plan-Do-Study-Act (PDSA) framework, focus groups were conducted to understand the communication needs of emergency department patients. An information design specialist co-created a graphic information system (the patient journey map) and worked with AHS communications to ensure it met AHS guidelines. Patients were then approached to participate in a 14-question survey about the usability and accuracy of the journey map as well as the impact it had on their ED visit. Our team consisted of Heather Hair, Executive Director of the (ESCN) who provided leadership in identifying communication as a key area for improvement and coordinating ED partners and patient involvement. Gillian Harvey is an assistant professor of Design Studies at the University of Alberta. She used the data collected in focus groups to design a 2-D communication map. David Stringer acted as project manager for the implementation and evaluation of the journey map. Stephanie Vandenberg is an emergency physician and was responsible for designing the evaluation strategy including research methods and data analysis. An official journey map is now available to print for emergency departments across Alberta. Evaluation Methods: The objective was to understand what information ED patients require during their visit to better understand the process by which they are triaged and receive care. Data collection consisted of a 10-minute, 14 question interview. Each question allowed for positive, neutral or negative feedback to capture unintended consequences of the journey map. Quantitative demographic and journey map-specific variables were collected and reported as frequencies. Qualitative data was analyzed using thematic analysis with thematic codes developed and assigned to the qualitative responses. Both quantitative and qualitative analysis was undertaken by two members of the research team. Responses were analyzed against the demographic variable of age category to determine if age impacts communication needs and desired medium of communication in the ED. Results: Seven hospitals took part in this survey, conducted between September 1, 2019 and May 5, 2020. 162 emergency department patients participated. Most people agreed that the journey map clarified the ED patient process and accurately reflected their experience of the ED journey. The journey map did not seem to make the wait less confusing. Participants reported the journey map was good at helping them understand the overall emergency department intake process and did a good job of helping them understand the reason for waiting/delays. The journey map was excellent at helping the participant understand why specific tests/treatments were needed but was poor at helping them to understand the total time it would take them to be seen.

DIZZINESS, PSYCHOSOCIAL FUNCTION, AND GAIT ASSESSMENT FOLLOWING SPORT-RELATED CONCUSSION

Background:Dizziness after concussion can be detrimental to both the physical and psychosocial wellbeing of patients. Vestibular symptoms, in particular, can amplify postural instability, which may create a greater sense of mental and physical abnormality post-concussion.Purpose:To examine the three-way association between self-reported dizziness with concussion symptoms, depression and anxiety severity, and gait deficits within two weeks post-concussion. We hypothesized that participants who endorsed a moderate/severe level of dizziness would report a more severe concussion symptom burden, more severe depression and anxiety, and worse postural stability.Methods:For this cross-sectional study, participants ages 14-21, were recruited from either a regional sports concussion clinic or emergency department, and tested within 14 days of a diagnosed concussion. Participants completed the Dizziness Handicap Inventory (DHI), Post-Concussion Symptom Inventory (PSCI), and Hospital Anxiety and Depression Scale (HADS).They also completed an instrumented single/dual-task gait assessment (three trials per condition). The gait assessment included walking at a self-selected pace towards a target 8m ahead, then returning to the start line. Dual task trials included a cognitive task (months in reverse order, serial 7’s, and spelling a 5-letter word backwards) while walking. Descriptive statistics, independent t-tests, and Mann Whitney U tests were used to compare between those with moderate/severe dizziness (DHI score ≥36) and those with mild/no dizziness (DHI score <36), p<0.05.Results:40 participants completed the study. 19 self-reported moderate/severe dizziness (63% female, 17.1±2.4 years of age, average DHI score 48.4±12.6) and 21 mild/no dizziness (38% females, 16.5±1.9 years of age, average DHI score 18.7±9.3). Those with moderate/severe dizziness reported significantly more severe symptoms (PSCI: 43.0±20.6 vs. 22.8±15.7, p=0.001), and had higher median HADS anxiety (6 vs. 2, p<0.001) and depression (6 vs. 1, p=0.001) scores than those with no/minimal dizziness. During steady-state gait, the moderate/severe dizziness group walked with significantly lower single-task cadence (Figure 1B) and dual-task cadence (Figure 1E) than the no/mild dizziness group.Conclusion:Participants who self-reported a moderate to severe level of dizziness within 14 days of a concussion reported worse symptom severity, anxiety, and depression than those with no/mild dizziness. Further, cadence during gait is negatively affected by the level of dizziness reported. Clinicians should be aware of the psychosocial and physical effects dizziness symptoms may play in a patient’s recovery. Gait deficits in the moderate/severe dizziness group further indicate the importance of evaluating how the feeling of postural instability affects gait following concussion. Word Count: 389/400 Figure 1.Single-task (A,B,C) and dual-task (D,E,F) steady-state gait performance comparisons between the moderate/severe and no/mild dizziness groups.

A solution to reducing avoidable emergency department visits: Implementation of an outpatient oncology acute care clinic.

e13517 Background: Emergency Department (ED) utilization by oncology patients accounts for more than 4.5 million visits in the United States annually, leading to hospitalization four times the rate of the general population.1,2 Many ED visits are the result of symptoms related to cancer or cancer treatment that can be managed on an outpatient basis. Unnecessary admissions lead to possible delays in cancer treatment and increased burden on healthcare resources.3 Simmons Acute Care (SAC), an advanced practice provider (APP)-led clinic, was established in August 2020 to provide an alternative model of oncology care to address these issues. Methods: A multidisciplinary team of key stakeholders was formed to develop an action plan. Institutional data was reviewed to identify the timing and volume of ED visits by oncology patients. Clinic hours were set Monday through Friday, 7:00am – 7:00pm, and referrals were made from primary oncology providers. Evidence-based clinical pathways were developed to standardize patient management, and a data collection plan was implemented to measure outcomes. Internal communications to patients and presentations at staff and faculty meetings occurred to inform patients and clinical staff/providers. Results: From August to December 2020, 165 patient visits were completed in SAC, 141 patients discharged home, 14 patients directly admitted to the hospital, and 10 patients transferred to the ED for a higher level of care. Based on data from 2020, the average cost of an ED visit for an oncology patient was $5,500 and increased to $28,500 if the patient is admitted. Patients with hematologic and gastrointestinal malignancies represented approximately 30% of all visits. Gastrointestinal symptoms were the most frequent presenting chief complaint. Conclusions: Supporting oncology patients in the ambulatory setting provided a reduction in admissions and unnecessary ED visits, leading to cost savings/avoidance to the patient and health system. Based on internal cost analyses, there are potential savings of over $2 million to the organization during this 5-month period. Additional studies are underway to assess patient satisfaction, as well as the economic impact for patients. 1. Rui PKK. National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf 2. Hong AS, Froehlich T, Clayton Hobbs S, Lee SJC, Halm EA. Impact of a Cancer Urgent Care Clinic on Regional Emergency Department Visits. J Oncol Pract. 2019;15(6):e501-e509. doi:10.1200/JOP.18.00743 3. Roy M, Halbert B, Devlin S, Chiu D, Graue R, Zerillo JA. From metrics to practice: identifying preventable emergency department visits for patients with cancer. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. Published online November 7, 2020. doi:10.1007/s00520-020-05874-3

Association Between Indigenous Status and Severity of Coronary Artery Disease: A Comparison of Coronary Angiogram Findings in Patients With Chest Pain Presenting to a Regional Hospital Emergency Department

Coronary artery disease (CAD) remains the leading cause of death amongst Indigenous Australians accounting for 12.1% of all deaths in this population. However, there is little evidence to suggest that Indigenous status is an independent risk factor for the development of coronary artery disease. This study assessed the association between Indigenous status and the severity of CAD in patients presenting with chest pain at a regional hospital emergency department. This was a retrospective single-centre audit over 12 months from January to December 2017. Charts were reviewed for both Indigenous and non-Indigenous patients 18 years and older who presented with chest pain and subsequently underwent an invasive coronary angiogram. Multivariable logistic regression was performed to examine the association of Indigenous status with the severity of CAD. Indigenous patients are 2.7 times more likely to experience significant CAD compared to non-Indigenous patients (Adjusted odds ratio [AOR]=2.73, 95% CI [1.38, 5.39], p≤0.001) even after adjusting for other risk factors. Those aged 65 years and older are more prone to significant CAD (AOR=2.96, 95% CI [1.12, 7.78], p=0.03), while women were less likely to have significant CAD compared to men, (AOR=0.46, 95% CI [0.27, 0.78], p<0.01). In this study cohort, our analysis indicates that there is a strong association between Indigenous status and significant coronary artery disease, independent of the increased burden of traditional cardiovascular risk factors among Indigenous Australians.

Higher daily pain severity after emergency department visits is associated with lower return-to-work rates

Pain can impair functional status, including a patient's ability to return to work. The purpose of this study was to determine whether there was an association between pain levels and return-to-work status during the first 4days post-ED discharge in ED patients seen for undifferentiated acute pain. This secondary analysis of data from the Acute Management of Pain from the Emergency Department (AMPED) registry included patients who reported working either full-time or part-time. We used Cox regression models to examine the association between daily self-reported minimum and maximum pain scores and first return to work. We used repeated measures logistic regression models to examine the association between daily minimum and maximum pain scores and daily return-to-work status. Of the 610 employed patients, 481 (78.9%) were employed full-time and 129 (21.1%) part-time. The average delay in returning to work after ED visit was 2.4days. For all models, higher minimum and maximum daily pain scores predicted lower daily return-to-work rates in the first four days post-ED discharge. The adjusted hazards ratios for first return to work were 0.91 (0.87, 0.96) and 0.93 (0.89, 0.97), while the adjusted odds ratios for daily return-to-work status were 0.80 (0.75, 0.85) and 0.88 (0.83, 0.93) for every one-point increase in minimum and maximum pain scores, respectively. Higher daily pain severity is associated with decreased return-to-work after ED visits for acute pain, highlighting the importance of adequate discharge pain management from the ED.

COVID-19 and Pediatric Emergency Department: The Impact of National Containment Measures on an Italian Regional Hub for COVID-19

Background: Numerous studies described the epidemiological link and main clinical features of pediatric COVID-19, during the first pandemic period, while this is the first study that encompass several different phases of National Lockdown in a European country. We described the effects of different National Containment Measures on positive NST (Nasopharyngeal Swab Test) trend, epidemiological links and main clinical features of the largest Italian Pediatric cohort admitted to a single regional Pediatric Emergency Department Hub for COVID-19, during an eight-month period.Methods: We described 316 patients with a positive NST for SARS-CoV2, on a total of 5001 nasopharyngeal swabs performed among 13171 admissions at our PED, over a period starting from March 17th, 2020 to December 1st, 2020. Age, epidemiological link, clinical features and hospitalizations were analyzed according to different lockdown phases. Data were collected anonymously from electronic records and analyzed using SPSS 22.00 statistics software (Chicago, IL).Findings: Thirty-six percent of total admissions have been tested for SARS-CoV2. During the post Lockdown period we performed the highest percentage of NST (Nasopharyngeal Swab Test) 49,7% and found the highest percentage of positive NST on total NST effectuated 7,9%. Mean age was 6.5 years old. The 0-6 years age group accounted the highest number of positive NST. Familial link is predominant during all phases; however, we observed an increase of extra-familial and unknown link starting from the phase 4, especially among adolescents. Seventeen patients showed an intra-scholastic link. Older children were frequently symptomatic and accounted for the 1% admission in ICU (Intensive Care Unit). Seven patients were admitted with MIS-C diagnosis.Interpretation: Different levels of containment measures caused important changes in epidemiological link, mean age and number of admissions and hospitalization of patients with COVID-19. Familial link was predominant in our cohort, during all phases of Lockdown, yet the impact on extrafamilial link and intra-scholastic link should be further investigated. Adolescent and young adults could present more frequently with moderate/severe symptoms requiring, in rare cases, admission in ICU.Funding Statement: No funding was secured for this study.Declaration of Interests: The authors have no conflicts of interest to disclose.Ethics Approval Statement: This study was approved by the institutional review board of BambinoGesù Children Hospital, IRCCS.

Emergency Department Utilization for Emergency Conditions During COVID-19

Study objectiveWe use a national emergency medicine clinical quality registry to describe recent trends in emergency department (ED) visitation overall and for select emergency conditions.MethodsData were drawn from the Clinical Emergency Department Registry, including 164 ED sites across 35 states participating in the registry with complete data from January 2019 through November 15, 2020. Overall ED visit counts, as well as specific emergency medical conditions identified by International Classification of Diseases, Tenth Revision, Clinical Modification code (myocardial infarction, cerebrovascular accident, cardiac arrest/ventricular fibrillation, and venous thromboembolisms), were tabulated. We plotted biweekly visit counts overall and across specific geographic regions.ResultsThe largest declines in visit counts occurred early in the pandemic, with a nadir in April 46% lower than the 2019 monthly average. By November, overall ED visit counts had increased, but were 23% lower than prepandemic levels. The proportion of all ED visits that were for the select emergency conditions increased early in the pandemic; however, total visit counts for acute myocardial infarction and cerebrovascular disease have remained lower in 2020 compared with 2019. Despite considerable geographic and temporal variation in the trajectory of the coronavirus disease 2019 outbreak, the overall pattern of ED visits observed was similar across regions and time.ConclusionThe persistent decline in ED visits for these time-sensitive emergency conditions raises the concern that coronavirus disease 2019 may continue to impede patients from seeking essential care. Efforts thus far to encourage individuals with concerning signs and symptoms to seek emergency care may not have been sufficient.

Association Between Indigenous Status and Severity of Coronary Artery Disease: A Comparison of Coronary Angiogram Findings in Patients With Chest Pain Presenting to a Regional Hospital Emergency Department

Coronary artery disease (CAD) remains the leading cause of death amongst Indigenous Australians accounting for 12.1% of all deaths in this population. However, there is little evidence to suggest that Indigenous status is an independent risk factor for the development of coronary artery disease. This study assessed the association between Indigenous status and the severity of CAD in patients presenting with chest pain at a regional hospital Emergency Department.

Effectiveness and cost-effectiveness of TeleStroke consultations to support the care of patients who had a stroke presenting to regional emergency departments in Western Australia: an economic evaluation case study protocol

IntroductionThe Western Australia (WA) Acute TeleStroke Programme commenced incrementally across regional WA during 2016–2017. Since the introduction of the TeleStroke Programme, there has been monitoring of service outputs, including regional...

Characterization and impact of COVID-19-tested and infected patients: Experience of The Johns Hopkins Health System Regional Emergency Departments.

BackgroundThere is limited understanding of the characteristics and operational burden of persons under investigation (PUIs) and those testing positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) presenting to emergency departments (EDs).MethodsWe reviewed all adult ED visits to 5 Johns Hopkins Health System hospitals in the Maryland/District of Columbia (DC) region during the initial coronavirus disease 2019 (COVID‐19) surge, analyzing SARS‐CoV‐2 polymerase chain reaction test eligibility, results, demographics, acuity, clinical conditions, and dispositions.ResultsOf 27,335 visits, 11,402 (41.7%) were tested and 2484 (21.8%) were SARS‐CoV‐2 positive. Test‐positive rates among Hispanics, Asians, African Americans/Blacks, and Whites were 51.6%, 23.7%, 19.8%, and 12.7% respectively. African American/Blacks infection rates (25.5%–33.8%) were approximately double those of Whites (11.1%–21.1%) in the 3 southern Maryland/DC EDs. Conditions with high test‐positive rates were fever (41.9%), constitutional (36.4%), upper respiratory (36.9%), and lower respiratory (31.2%) symptoms. Test‐positive rates were similar in all age groups (19.9% to 25.8%), although rates of hospitalization increased successively with age. Almost half, 1103 (44.4%), of test‐positive patients required admission, of which 206 (18.7%) were to an ICU.ConclusionThe initial surge of SARS‐CoV‐2 test‐positive patients experienced in a regional hospital system had ≈ 42% of patients meeting testing criteria and nearly one‐fifth of those testing positive. The operational burden on ED practice, including intense adherence to infection control precautions, cannot be understated. Disproportionately high rates of infection among underrepresented minorities underscores the vulnerability in this population. The high rate of infection among self‐identified Asians was unexpected.

Validity and reliability of the triage scale in older people in a regional emergency department in Hong Kong

Background: Older people (⩾65 years) present a unique challenge in emergency department triage. Hong Kong’s Hospital Authority adopts a five-level emergency department triage system, with no special considerations for older people. We evaluated the validity and reliability of this triage scale in older people in a regional Hong Kong emergency department. Methods: In total, 295 cases stratified by triage category were randomly selected for review from November 2016 to January 2017. Validity was established by comparing the real emergency department patients’ triage category against (1) that of an expert panel and (2) the need for life-saving intervention. Triage notes were extracted to make case scenarios to evaluate inter- and intra-rater reliabilities. Emergency department nurses (n = 8) were randomly selected and grouped into &lt;5 and ⩾5 years emergency department experience. All nurses independently rated all 295 scenarios, blinded to clinical outcomes. Results: The percentage agreement between the real emergency department patients’ triage category and the expert panel’s assignment was 68.5%, with 16.3% and 15.3% over-triage and under-triage, respectively. Quadratic weighting kappa for agreement with the expert panel was 0.72 (95% confidence interval: 0.53–0.91). The sensitivity, specificity and positive likelihood ratio for the need for life-saving interventions were 75.0% (95% confidence interval: 47.6%–92.7%), 97.1% (95% confidence interval: 94.4%–98.8%) and 26.2 (95% confidence interval: 12.5%–54.8%), respectively. The Fleiss kappa value for inter-rater reliability was 0.50 (95% confidence interval: 0.47–0.54) for junior and senior nurse groups, respectively. Conclusion: The current triage scale demonstrates reasonable validity and reliability for use in our older people. Considerations highlighting the unique characteristics of older people emergency department presentations are recommended.

Type of facility influences lengths of stay of children presenting to high volume emergency departments

BackgroundEmergency department crowding may impact patient and provider outcomes. We describe emergency department crowding metrics based on presentations by children to different categories of high volume emergency departments in Alberta, Canada.MethodsThis population-based retrospective study extracted all presentations made by children (age < 18 years) during April 2010 to March 2015 to 15 high volume emergency departments: five regional, eight urban, and two academic/teaching. Time to physician initial assessment, and length of stay for discharges and admissions were calculated based on the start of presentation and emergency department facility. Multiple metrics, including the medians for hourly, facility-specific time to physician initial assessment and length of stay were obtained.ResultsAbout half (51.2%) of the 1,124,119 presentations were made to the two academic/teaching emergency departments. Males presented more than females (53.6% vs 46.4%) and the median age was 5 years. Pediatric presentations to the three categories of emergency departments had mostly similar characteristics; however, urban and academic/teaching emergency departments had more severe triage scores and academic/teaching emergency departments had higher admissions. Across all emergency departments, the medians of the metrics for time to physician initial assessment, length of stay for discharges and for admission were 1h11min, 2h21min, and 6h29min, respectively. Generally, regional hospitals had shorter times than urban and academic/teaching hospitals.ConclusionsPediatric presentations to high volume emergency departments in this province suggest similar delays to see providers; however, length of stay for discharges and admissions were shorter in regional emergency departments. Crowding is more common in urban and especially academic emergency departments and the impact of crowding on patient outcomes requires further study.