Repeat Emergency Department Visits Research Articles

Peritonsillar Abscess Outcomes with and Without Computed Tomography: A Retrospective Cohort Study.

Peritonsillar abscess (PTA) is a common deep space head and neck infection, which can be diagnosed with or without computed tomography (CT). CT poses a risk for false positives, leading to unnecessary abscess drainage attempts without benefit, whereas needle or open aspiration without imaging could potentially lead to missed abscess in need of treatment. This study considered the utility and impact of obtaining CT scans in patients with suspected PTA by comparing outcomes between CT and non-CT usage. Retrospective cohort analysis using TriNetX datasets compared the outcomes of two cohorts: PTA without CT and PTA with CT. Measured outcomes included incision and drainage; quinsy adenotonsillectomy; recurrent PTA; airway emergency/obstruction; repeat emergency department (ED) visits; and need for antibiotics, opiates, or steroids. Odds ratios (OR) were calculated using a cohort analysis. The CT usage group had increased odds of receiving antibiotics (OR 3.043, [2.043-4.531]), opiates (OR 1.614, [1.138-1.289]), and steroids (OR 1.373, [1.108-1.702]), as well as a higher likelihood of returning to the ED (OR 5.900, [3.534-9.849]) and developing a recurrent PTA (OR 1.943, [1.410-2.677]). No significant differences were observed in the incidence of incision and drainage, quinsy adenotonsillectomy, or airway emergency/obstruction. Our study indicated that CT scans for PTA diagnosis were associated with increased prescription of antibiotics, opioids, steroids, return ED visits, and recurrent PTA. Future prospective trials are needed to determine if the use of CT scans indicates higher patient acuity that explains the potential negative outcomes. Level II Laryngoscope, 2024.

A real-world evaluation of the effectiveness and Sufficiency of Current Emergency Department Preventative Strategies for Reducing Emergency Department revisits in a Canadian children’s hospital: a retrospective cohort study

BackgroundDespite asthma guidelines’ recommended emergency department preventative strategies (EDPS), repeat asthma-related emergency department (ED) visits remain frequent.MethodsWe performed a retrospective cohort study of children aged 1–17 years presenting with asthma to the Children’s Hospital of Eastern Ontario (CHEO) ED between September 1, 2014 – August 31, 2015. EDPS was defined as provision of education on trigger avoidance and medication technique plus documentation of an asthma action plan, a prescription for an inhaled controller medication or referral to a specialist. Logistic regression was used to identify factors associated with receipt of EDPS. We further compared the odds of repeat presentation to the ED within the following year among children who had received EDPS versus those who had not.Results1301 patients were included, and the mean age of those who received EDPS was 5.0 years (SD = 3.7). Those with a moderate (OR = 3.67, 95% CI: 2.49, 5.52) to severe (OR = 3.69, 95% CI: 2.50, 5.45) asthma presentation were most likely to receive EDPS. Receiving EDPS did not significantly reduce the adjusted odds of repeat ED visits, (OR = 0.82, 95% CI: 0.56, 1.18, p = 0.28).ConclusionsPatients with higher severity asthma presentations to the ED were more likely to receive EDPS, but this did not appear to significantly decrease the proportion with a repeat asthma ED visit. These findings suggest that receipt of EDPS in the ED may not be sufficient to prevent repeat asthma ED visits in all children.

A Comprehensive Evaluation of Emergency Department Utilization by Patients With Cirrhosis.

Emergency department (ED)-based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) vs non-HEDU in individuals with cirrhosis. We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. There were 2,124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), metabolic dysfunction-associated steatohepatitis (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits, 20% (n = 424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were model for end-stage liver disease-sodium (adjusted odds ratio [aOR] 1.044, 95% confidence interval [CI] 1.005-1.085), prior ED encounter (aOR 1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR 1.938, 95% CI 1.014-3.703). Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.

Pediatric Outcomes of Emergency Medical Services Non-Transport Before and During the COVID-19 Pandemic.

Pediatric patients account for 6-10% of emergency medical services (EMS) activations in the United States. Approximately 30% of these children are not transported to an emergency department (ED). Adult data in the literature reports higher hospitalization and complications following non-transport. Few studies discuss epidemiology and characteristics of pediatric non-transport; however, data on outcome is limited. Our primary aim was to determine outcomes of non-transported children within our urban EMS system before and during the COVID-19 pandemic. Our secondary objective was to explore reasons for non-transport. This was a prospective, descriptive pilot study. We compared EMS data for September 2019 (pre-COVID-19) to September 2020 (pandemic). Included were children aged 0-17years who activated EMS and did not receive transport to the primary hospital for the EMS capture area. We defined outcomes as repeat EMS activation, ED visits, and hospital admissions, all within 72 hours. Data was obtained via electronic capture. We used descriptive statistics to analyze our data, chi square for categorical data, stepwise logistic regression, and univariate logistic regression to test for association of covariates with non-transport. There were 1,089 pediatric EMS activations in September 2019 and 780 in September 2020. Non-transport occurred in 633 (58%) in September 2019 and 412 (53%) in September 2020. Emergency medical services was reactivated within 72 hours in the following: 9/633 (1.4%) in 2019; and 5/412 (1.2%) in 2020 (P = 0.77). Visits to the ED occurred in 57/633 (9%) in 2019 and 42/412 (10%) in 2020 (P = 0.53). Hospital admissions occurred in 10/633 (1.5%) in 2019 and 4/412 (0.97%) in 2020 (P = 0.19). One non-transported patient was admitted to the intensive care unit in September 2020 (<1%) and survived. Hispanic ethnicity, age >12years, and fever were associated with repeat EMS activation. The most common reason for non-transport in both study periods was that the parent felt an ambulance was not necessary (47%). In our system, non-transport of pediatric patients occurred in >50% of EMS activations with no significant adverse outcome. Age >12years, fever, and Hispanic ethnicity were more common in repeated EMS activations. The most common reason for non-transport was parents feeling it was not necessary. Future studies are needed to develop reliable EMS guidelines for pediatric non-transport.

Evaluating the impact of a discharge pharmacy in the emergency department on emergency department revisits and admissions

ImportanceMedication nonadherence leads to worse health outcomes, increased healthcare service utilization, and increased overall healthcare costs. ObjectiveTo determine whether a discharge pharmacy located in the Emergency Department (ED) reduces ED revisits and hospitalizations. DesignThis is a cohort study where we extracted data from our electronic medical records with adult encounters between 12/2019–10/2021. For the purpose of this study, we defined a revisit to the ED as within 7 days and an admission within 30 days from prior initial ED visit. SettingThe University of Chicago Medicine is an academic medical center located in Chicago's South Side. ParticipantsBetween dates of 12/2019–11/2021, we had 78,660 adult distinct encounters. We created 5 different groups: no medications prescribed, ED discharge pharmacy only, e-prescriptions to outside pharmacies, combination of ED pharmacy and e-prescription sent elsewhere, and printed prescriptions with or without any e-prescriptions. ExposureOur ED pharmacy is located within the adult ED, serving only patients seen and discharged from the adult ED. Main Outcome(s) and Measure(s)Our primary endpoint is to evaluate if prescribing and dispensing prescriptions from only our ED pharmacy is associated with decreased ED revisits within 7 days and reduced hospitalizations within 30 days of initial ED visit. ResultsWhen comparing patients who received prescriptions only from the ED discharge pharmacy, patients who received no prescriptions were 31.6% (P < 0.001) more likely to revisit our ED, and patients who received e-prescriptions sent to other pharmacies were 10.4% (P = 0.017) more likely to revisit. Patients who received e-prescriptions from other pharmacies were 29.2% (P < 0.001) more likely to be hospitalized and mixture of e-prescriptions were 59.5% (P < 0.001) more likely to be hospitalized compared to the ED pharmacy only group. Conclusions and RelevanceWe believe having a pharmacy providing medications to patients being discharged from the ED reduces barriers like cost, transportation, and pharmacy access patients face trying to fill prescriptions at their local pharmacy. All of these reductions in barriers provides an easier and more convenient method for patients to obtain their medications at discharge from the ED, reducing the risk of a repeat ED visit and subsequent hospital admission.

Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report

BackgroundDiagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. Case ReportWe present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an “intrauterine gestational sac” along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. Why Should an Emergency Physician Be Aware of This?This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to “clinically correlate.”

2949. Emergency Department (ED) Discharge Antibiotic Prescription Review by Hospital Pharmacists at a Large Academic Medical Center

Abstract Background Direct patient discharge from the Emergency Department (ED) presents an ideal time to promote antimicrobial stewardship (AS). On March 1, 2021 we initiated a pilot program where ED pharmacists conduct a review of discharge antibiotic prescriptions (abx Rxs). The aim of this program is to ensure appropriate discharge abxs. Willow Pharmacy Epic Analysts, ED and AS pharmacists collaborated on this program which included Epic integration of Rx Discharge Track Board, ED Discharge InBasket, ED Discharge Rx iVent and AS-led education sessions. Methods Data for 2022 ED patients with discharge abx Rxs and iVents were extracted via Epic Reports. The first encounter per patient was included. We compared discharge abx Rxs and patient outcome data in Pharmacy vs No Pharmacy Review Groups (PRG, NPRG). Pharmacy iVents were used as a process measure. Results Among 5747 ED adult patients with discharge abx Rxs, 2638 (46%) were reviewed by pharmacy (PRG). PRG and NPRG had similar prevalence of chronic pulmonary disease (12% vs. 13%), diabetes mellitus (9% vs. 10%), malignancy (8% vs. 9%), peripheral vascular disease (6% vs. 8%), renal disease (4% vs. 5%), and HIV (1% vs. 2%) despite a difference in mean Charlson Comorbidity Index (0.64 vs 0.75, p&amp;lt; 0.01). The primary ED diagnosis was skin and soft tissue, urinary, intra-abdominal infections and pneumonia (25 vs 23%, 18 vs 17%, 8 vs 9%, 5 vs 6%, respectively all p=NS). In PRG, discharge abxs demonstrated an increase use of penicillin (26 vs 24%, p=0.017) and 2nd generation cephalosporin (17 vs 14%, p&amp;lt; 0.001). The PRG also decreased use of 3rd generation cephalosporin (11 vs 12%, p=NS), quinolones (6 vs 7%, p=NS) and clindamycin (1.7 vs 2.4%, p=NS). There was no difference in ED length of stay (LOS 4.8h in each group), C. difficile infection (CDI) within 8 weeks (0.1 vs 0.2%, p=NS), and 30 days repeat ED visit or inpatient admission with the same diagnosis as index ED encounter (2.8 vs 2.6%, p=NS). Pharmacists intervened in 10% (272/2638) of ED abx Rxs with 92% (249/272) acceptance rate. The top 3 pharmacy interventions were recommending alternative abx (42%), dose optimization (31%) and abx duration (6%). Conclusion Engaging pharmacists in ED discharge Rxs review resulted in use of narrower spectrum abx with lower CDI risk without any negative impact on ED LOS and clinical outcomes. Disclosures All Authors: No reported disclosures

Impact of Emergency Department-Initiated Buprenorphine on Repeat Emergency Department Utilization.

Recent studies have demonstrated the promise of emergency department (ED)-initiated buprenorphine/naloxone (bup/nx) for improving 30-day retention in outpatient addiction care programs for patients with opioid use disorder (OUD). We investigated whether ED-initiated bup/nx for OUD also impacts repeat ED utilization. We performed a retrospective chart review of ED patients discharged with a primary diagnosis of OUD from July 2019-December 2020. Characteristics considered included age, gender, race, insurance status, domicile status, presence of comorbid Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, presenting chief complaint, and provision of a bup/nx prescription and/or naloxone kit. Primary outcomes included repeat ED visit (opioid or non-opioid related) within 30 days, 90 days, and one year. Statistical analyses included bivariate comparison and Poisson regression. Of 169 participants, the majority were male (67.5%), White (82.8%), uninsured (72.2%), and in opioid withdrawal and/or requesting "detox" (75.7%). Ninety-one (53.8%) received ED-initiated bup/nx, which was independent of age, gender, race, insurance status, presence of comorbid DSM-5 diagnosis, or domicile status. Naloxone was more likely to be provided to patients who received bup/nx (97.8% vs 26.9%; P < 0.001), and bup/nx was more likely to be given to patients who presented with opioid withdrawal and/or requested "detox" (63.3% vs 36.7%; P < 0.001). Bup/nx provision was associated with decreased ED utilization for opioid-related visits at 30 days (P = 0.04). Homelessness and lack of insurance were associated with increased ED utilization for non-opioid-related visits at 90 days (P = 0.008 and P = 0.005, respectively), and again at one year for homelessness (P < 0.001). When controlling for age and domicile status, the adjusted incidence rate ratio for overall ED visits was 0.56 (95% confidence interval [CI] 0.33-0.96) at 30 days, 0.43 (95% CI 0.27-0.69) at 90 days, and 0.60 (95% CI 0.39-0.92) at one year, favoring bup/nx provision. Initiation of bup/nx in the ED setting was associated with decreased subsequent ED utilization. Socioeconomic factors, specifically health insurance and domicile status, significantly impacted non-opioid-related ED reuse. These findings demonstrate the ED's potential as an initiation point for bup/nx and highlight the importance of considering the social risk and social need for OUD patients.

Abstract 16662: Factors Associated With Repeated Emergency Department Visits Among Symptomatic Patients With Heart Failure

Heart failure (HF) is a prevalent cause of emergency department (ED) visits among adults. However, there is limited understanding of the characteristics of patients with HF who frequently utilize the ED for symptom management. Aim: To describe factors associated with ED revisits among symptomatic patients with chronic HF. Methods: We identified 1,472,083 adults (age ≥ 18 years) with HF who had no history of left ventricular assist device or heart transplantation between January 2010 and March 2020 from the TriNetX Research Network, which included 47 US healthcare organizations. In this retrospective observational study, 24,070 patients presenting with dyspnea and receiving intravenous (IV) Furosemide at the ED were followed up for 1 year from the index ED visit. ED revisits related to the treatment of dyspnea with IV diuretics were tracked. Factors associated with these ED revisits were identified using multivariate Cox regression analysis. Results: A total of 3,574 ED revisits were observed from 2,559 patients (10.6% of the sample, mean age 63 years, 51% men, 39% White, 62% Non-Hispanic). The ED revisit rates were 52, 96, 125, and 148 visits per 1,000 persons within 1, 3, 6, and 12 months, respectively. The median time to the first ED revisit for symptom management with IV diuretics was 65 days (range 2-364 days). In the Cox model, younger patients (&lt; 65 years) had a higher risk of ED revisits compared to older patients (HR 1.65, 95% CI 1.50-1.82, p&lt;0.001). Men had a higher risk of ED revisits compared to women (HR 1.12, 95% CI 1.02-1.23, p=0.02). Black patients had a higher risk of ED revisits compared to other races (HR 1.36, 95% CI 1.20-1.53, p&lt;0.001). Patients with HFrEF (e.g., ICD-10 I50.2) had a higher risk of ED revisits compared to those with congestive HF (e.g., ICD-10 I50 without HF type information) (HR 1.25, 95% CI 1.12-1.40, p &lt; 0.001). Patients diagnosed with HF more than 1 year prior to the index ED visit had a higher risk of ED revisits compared to those diagnosed within 1 year (HR 1.31, 95% CI 1.19-1.44, p &lt; 0.001). Conclusions: Younger age, male gender, Black race, HFrEF classification, and longer duration of HF were associated with ED revisits among symptomatic adults with HF. To reduce repeated ED visits, targeted interventions for high-risk patients are essential.

(310) Nationwide Priapism Emergency Department Encounters in the United States

Abstract Introduction There is a lack of understanding of recent trends and costs in emergency department visits and inpatient admissions for priapism. In particular no studies have evaluated nationwide trends in priapism since the roll out of ICD-10CM coding in 2015. Objective To determine contemporary national estimates for emergency department visits and inpatient admissions for priapism in the United States from 2016-2019. Methods Emergency department (ED) encounters for priapism were analyzed using the Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project (HCUP). Patients presenting to the ED with a diagnosis of priapism were identified by ICD-10-CM codes. Patient demographics, hospital characteristics, patient disposition, and costs were evaluated for each visit. Statistical analysis was performed using established weighting provided by the HCUP to create national estimates. Comparisons of demographics were performed using t-tests and chi-square tests with a p-value for significance &amp;lt;0.05. Prolonged length of stay was defined as over two days. Results Between 2016-2019, there was a weighted total of 78,993 ED visits for priapism nationwide out of an estimated 576,544,259 ED encounters making up 0.014% (p&amp;lt;0.01) of all ED encounters. The average age of a patient diagnosed with priapism was 41 (SEM=0.102). Patients diagnosed with unspecified priapism made up 73.67% (58,197) of encounters, while those diagnosed with drug-induced priapism accounted for 14.34% (11,325) of encounters, and 7.26% (5,738) encounters of priapism were due to disease. The South region had the greatest number of priapism encounters each year accounting for 46.59% (36,800) of all ED visits mostly in metropolitan teaching hospitals hosted 70.53% (55,713). Inpatient admissions occurred in 16.07% (12,696) of ED visits for priapism. Of those admitted, 79.10% (10,043) had a prolonged length of stay with those staying only a day making up 16% (2,031). Inpatient admissions averaged a total charge of $72,668 compared with $3,763 (p&amp;lt;.0001) for patients not admitted. Of the expected primary payers, private insurance covered 32.14% (25,356) of ED visits for priapism with Medicaid covering 30.24% (23,857), Medicare covering 17.50% (13,805), and self-payers covering 14.77% (11,648). Conclusions ED visits for priapism remain a frequent and costly event in the United States Healthcare System. Patients requiring inpatient admission leads to a significantly increased cost for the overall encounter. Future studies should examine interventions that can decrease repeated ED visits and inpatient admission for priapism on a regional and national level. Disclosure No

Predictors of suicide coping self-efficacy among youth presenting to a psychiatric emergency department.

Low levels of youth-reported self-efficacy to cope with suicidal urges have been shown to prospectively predict repeat emergency department (ED) visits and suicide attempts, yet little is known about how self-efficacy may change following receipt of crisis services or about factors that may strengthen self-efficacy. Protective factors (e.g., parent-reported youth competence, parent-family connectedness, and receipt of mental health services) were examined in relation to self-efficacy at the time of a psychiatric ED visit and 2 weeks later. Participants were 205 youth (ages 10-17), presenting to a psychiatric ED due to a suicide-related concern. Youth primarily identified as biological female (63%) and White (87%). Multivariate hierarchical linear regressions were used to examine candidate protective factors in relation to initial and follow-up suicide coping self-efficacy. Self-efficacy significantly improved in the 2 weeks following the ED visit. Parent-family connectedness was positively related to suicide coping self-efficacy at the time of the ED visit. Parent-family connectedness and receipt of inpatient psychiatric care following the ED visit were associated with higher follow-up suicide coping self-efficacy. During the adolescent developmental period when suicidal thoughts and behaviors notably increase, study findings highlight potential malleable intervention targets, including parent-family connectedness, that may strengthen suicide coping self-efficacy.

Gaps in care following first time seizure in an underserved region: A retrospective analysis

PurposeThis study investigated the characteristics of patients presenting with the first-time seizure (FTS) and whether neurology follow-up occurred in a medically underserved area. MethodsA retrospective study of adults with a FTS discharged from the Emergency Department (ED) at Loma Linda University between January 1, 2017 and December 31, 2018 was performed. The primary outcome was days from the ED visit to the first neurology visit. Secondary outcomes included repeat ED visits, percentage of patients who had specialty assessment in one year, type of neurologist seen, and percentage lost to follow-up. ResultsOf the 1327 patients screened, 753 encounters met criteria for manual review, and after exclusion criteria were applied, 66 unique encounters were eligible. Only 30% of FTS patients followed up with a neurologist. The median duration for neurology follow-up was 92 days (range=5–1180). After initial ED visit, 20% of follow-up patients were diagnosed with epilepsy within 189 days, and 20% of patients re-presented to the ED with recurrent seizures while awaiting their initial neurology appointment. Reasons for lack of follow-up included: referral issues, missed appointments, and shortage of available neurologists. ConclusionThis study highlights the significant treatment gap that a first-time seizure clinic (FTSC) could fill in underserved communities. FTSC may reduce the morbidity and mortality associated with untreated recurrent seizures.

Pediatric emergency department use by Afghan refugees at a temporary housing facility.

In August 2021, "Operation Allies Welcome" evacuated 76,000 Afghan refugees to 8 US temporary housing facilities. The impact of refugee influx on local emergency department (ED) use and the resources needed during resettlement are poorly described. We report the frequency of pediatric ED visits and characterize the ED resources needed by pediatric Afghan refugees from 1 temporary housing facility. This single-center, retrospective cohort study identified participants via a refugee identifier in the medical record. The primary outcome was the frequency and timing of pediatric ED visits; secondary outcomes included resources used during ED evaluation and management. Trained reviewers collected data using a predefined instrument and descriptive statistics are reported. This study included 175 pediatric ED visits by Afghan refugees. The highest volumes (n=73, 42%) occurred 3-5weeks after evacuation. Common presenting complaints included fever (36%), gastrointestinal (15%), and respiratory (13%). Resources used included radiography (64%), lab testing (63%), and medication (78%). Specialist consultation occurred in 43% of visits; infectious diseases (17%) and neurology (15%) were the most common. Discharge (61%) was more common than admission (39%), though 31% of discharged patients had a repeat ED visit. Only 51% attended a recommended follow-up appointment. In this study, most pediatric ED visits by refugees occurred within 5weeks of arrival. Most patients were discharged after diagnostic testing, medication, and specialist consultation, but repeat ED visits were common. These patterns have important implications in preparing for future mass displacement events.

MP10-13 ONGOING IMPROVEMENT IN ACCESS AND QUALITY OF CARE FOR KIDNEY STONE PATIENTS IN AN UNDERSERVED COMMUNITY: A THREE YEAR PROGRAM UPDATE

You have accessJournal of UrologyCME1 Apr 2023MP10-13 ONGOING IMPROVEMENT IN ACCESS AND QUALITY OF CARE FOR KIDNEY STONE PATIENTS IN AN UNDERSERVED COMMUNITY: A THREE YEAR PROGRAM UPDATE Megan Stout, Molly McNamara, Aliza Khuhro, Matthew Murtha, Max Yudovich, Alicia Scimeca, Dinah Diab, Tasha Posid, Ganesh Shidham, Elizabeth Weinandy, Bodo Knudsen, and Michael Sourial Megan StoutMegan Stout More articles by this author , Molly McNamaraMolly McNamara More articles by this author , Aliza KhuhroAliza Khuhro More articles by this author , Matthew MurthaMatthew Murtha More articles by this author , Max YudovichMax Yudovich More articles by this author , Alicia ScimecaAlicia Scimeca More articles by this author , Dinah DiabDinah Diab More articles by this author , Tasha PosidTasha Posid More articles by this author , Ganesh ShidhamGanesh Shidham More articles by this author , Elizabeth WeinandyElizabeth Weinandy More articles by this author , Bodo KnudsenBodo Knudsen More articles by this author , and Michael SourialMichael Sourial More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003225.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is a call to improve Medicaid patient access to healthcare, enhance quality and outcomes of care, and reduce overall financial burden. We sought to build a comprehensive kidney stone program to help patients navigate through the acute and preventative aspects of stone disease by increasing multidisciplinary referrals, compliance to recommendations, no-show rates at first follow-up, and repeat stone encounters after initial evaluation. METHODS: A collaborative, multi-disciplinary program was established at our single institution consisting of urology, nephrology, and dietary specialists to be piloted over a three-year period. Medicaid-designated patients were evaluated for during new patient encounters by urology and then followed for outpatient follow-up including specialty referrals to nephrology and dietitians when indicated for targeted preventative measures. Subjective compliance reports by patients following interventions and no-show rates at subsequent follow-ups were documented. We also followed patients 6 months beyond initial encounter to assess for repeat Emergency Department (ED) visits for acute stone episodes. RESULTS: One hundred and eighty-three Medicaid-designated stone patients were evaluated from 2018-2021. Sixty-eight percent of patients identified as white, 18% identified as black/African-American, and 14% identified as “other”. Patients underwent specialty referrals to nephrology or a dietician in 47% and 42% of cases, respectively. Since the program’s implementation, reported patient compliance and referrals to multidisciplinary specialists increased from 72.9% to 81.3% and 21.2% to 56.2%, respectively. Repeat Emergency Department visits for stone related encounters within 6 months of initial presentation remained relatively stable (from 17.6% to 18.9%) while no-show rates at first follow-up decreased from 20.0% to 6.3% by study conclusion. CONCLUSIONS: There is continued supporting evidence for the importance of a comprehensive kidney stone program specifically for patients of lower socioeconomic status following a three-year implementation at our institution. Encouraging results indicate increased access to multi-disciplinary specialty referrals, with improvement in follow-up and reported compliance related to stone prevention strategies. Source of Funding: The Upper Payment Limit Grant of The Ohio State University © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e119 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Megan Stout More articles by this author Molly McNamara More articles by this author Aliza Khuhro More articles by this author Matthew Murtha More articles by this author Max Yudovich More articles by this author Alicia Scimeca More articles by this author Dinah Diab More articles by this author Tasha Posid More articles by this author Ganesh Shidham More articles by this author Elizabeth Weinandy More articles by this author Bodo Knudsen More articles by this author Michael Sourial More articles by this author Expand All Advertisement PDF downloadLoading ...

MP72-10 UROLITHIASIS IN THE EMERGENCY DEPARTMENT: RESULTS OF A COLLABORATIVE QUALITY IMPROVEMENT PROJECT

You have accessJournal of UrologyCME1 Apr 2023MP72-10 UROLITHIASIS IN THE EMERGENCY DEPARTMENT: RESULTS OF A COLLABORATIVE QUALITY IMPROVEMENT PROJECT Kimberly Kocour, Eliza Defroda, Elizabeth Malm-Buatsi, Mark Wakefield, Chase Schlesselman, Katie Murray, and Geoffrey Rosen Kimberly KocourKimberly Kocour More articles by this author , Eliza DefrodaEliza Defroda More articles by this author , Elizabeth Malm-BuatsiElizabeth Malm-Buatsi More articles by this author , Mark WakefieldMark Wakefield More articles by this author , Chase SchlesselmanChase Schlesselman More articles by this author , Katie MurrayKatie Murray More articles by this author , and Geoffrey RosenGeoffrey Rosen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urolithiasis is a frequent cause for emergency department (ED) visits. For some, urology consults are indicated, while for many, outpatient follow up is appropriate. We noted an opportunity to improve care for patients with newly diagnosed urolithiasis in our ED. We completed a quality improvement project to improve patient triage and decrease time to follow up, with the hypothesis that the protocol would lead to fewer ED revisits and improved patient management. METHODS: We created the MU Pathway for Particularly Expeditious Treatment of Stones (MUPPETS) which couples an ED stone triage protocol with early urologic follow up. The protocol helped identify patients who did not need a urology consult. For these patients, a new follow-up order was created which scheduled patients for a urology visit (typically by phone) within 72 hours. After creation of the protocol, educational sessions were given to Urology and ED at our institution. We retrospectively reviewed ED visits with kidney or renal stone diagnoses where the patient was discharged from the ED. Chi-squared tests were used to compare outcomes in the first 30 days after the ED visit. RESULTS: Protocol was initiated in March 2022. We identified 546 patients in the pre-intervention period (Dec 2020-Feb 2022), and 269 patients in the post-intervention period (Apr-Sep 2022). Narcotic prescribing decreased after our education sessions (38% vs 30%, p=0.02, figure 1a). 137 patients had the follow up order placed. These patients were more likely to have urology follow-up (62% vs 15%, p<0.0001) and urological surgery (15% vs 8%, p=0.008) in the first 30 days than those with no order. Patients who completed a follow up visit according to the protocol were less likely to have an ED visit in the first 30 days than those who did not (25% vs 49%, p=0.0004, figure 1b). CONCLUSIONS: We developed a quality improvement intervention aimed at improving triage of patients with urolithiasis and ensuring prompt follow up for those discharged from the ED. Implementation of this protocol at our institution significantly improved time to evaluation and treatment, and decreased repeat ED visits. This collaborative effort of urology and ED has the potential to improve patient care most importantly, but in turn could decrease unnecessary health care costs and narcotic use in urolithiasis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1028 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kimberly Kocour More articles by this author Eliza Defroda More articles by this author Elizabeth Malm-Buatsi More articles by this author Mark Wakefield More articles by this author Chase Schlesselman More articles by this author Katie Murray More articles by this author Geoffrey Rosen More articles by this author Expand All Advertisement PDF downloadLoading ...

Trends of repeated emergency department visits among adolescents and young adults for substance use: A repeated cross-sectional study.

Emergency Department (ED) visits for substance-related concerns among young people have been increasing in recent years. Understanding the factors related to repeated ED visits (two or more ED visits per year) for substance use concerns among young people is critical to developing a more efficient mental healthcare system that does not overburden ED and that provides efficient care for substance use patients. This study examined trends of substance use-related ED visits and factors related to repeated ED visits (two or more ED visits per year, in comparison to one ED visit per year) among adolescents and young adults (aged 13 to 25 years) in the province of Ontario, Canada. Binary logistic regression models were conducted to examine associations between hospital-related factors (hospital size, urbanicity, triage level, ED wait time) and visit status (2+ vs 1 ED visit/year), controlling for patient characteristics (age/sex). A population-based, repeated cross-sectional data over a 10-year period (2008, 2013, and 2018) was used. The proportion of substance use-related repeated ED visits significantly and consistently increased in the year 2013 and 2018 compared to 2008 (2008 = 12.52%, 2013 = 19.47%, 2018 = 20.19%). Young adult, male, medium-sized hospital, urban location, wait times longer than 6 hours, and symptom severity was associated with increased numbers of repeated ED visits. Furthermore, polysubstance use, opioid use, cocaine use, and stimulant use were strongly associated with repeated ED visits compared with the use of substances such as cannabis, alcohol and sedatives. Current findings suggest that repeated ED visits for substance use concerns could be reduced by policies that reinforce evenly distributed mental health and addiction treatment services across the provinces in rural areas and small hospitals. These services should put special efforts into developing specific (e.g., withdrawal/treatment) programming for substance-related repeated ED patients. The services should target young people using multiple psychoactive substances, stimulants and cocaine.

Patient experiences of a care transition intervention for Veterans to reduce emergency department visits.

Care transition interventions (CTIs) are used to improve outcomes after an emergency department (ED) visit. A recent randomized controlled trial of a Veterans Health Administration (VHA) CTI titled Discharge Information and Support for Patients receiving Outpatient care in the ED (DISPO ED) demonstrated no difference in repeat ED visits. However, changes in health care utilization are not the only measures of a CTI worth evaluation, and there is interest in using patient-centered outcomes to assess CTIs as well. To inform future CTI design and outcome measure selection, the study aims were to understand how patients experienced the CTI and what elements they valued. This was a qualitative study of participants randomized to the intervention arm of the DISPO ED trial using semistructured interviews. The interview guide included questions about clinical health and other issues addressed by the study nurse, the most and least helpful aspects of the intervention, and impacts of the intervention on their perceptions of self-management. Interviews were analyzed using directed content analysis. Our sample comprised 24 participants, with average age of 61 years, 58% male, and 50% Black or African American. We identified six major themes related to (1) experiences during the intervention and (2) elements they valued. Patients reported clinical health coaching recommendations covering a wide range of topics as well as care coordination actions such as appointment scheduling. Valuable elements of the intervention highlighted personal characteristics of the study nurse that promoted a sense of interpersonal connection and empathy in their interactions. Intervention users described assistance with care coordination as well as clinical concerns. We identified aspects that were highly valued by the participants, such as interpersonal support and empathy from the interventionist. These findings suggest the need for more comprehensive nonutilization outcome measures for CTIs to capture the patient's perspective.

Use of an Agitation Measure to Screen for Suicide and Self-Harm Risk Among Emergency Department Patients.

Suicidality alone is insensitive to suicide risk among emergency department (ED) patients. We describe the performance of adding an objective assessment of agitation to a suicide screening instrument for predicting suicide and self-harm after an ED encounter. We tested the performance of a novel screener combining the presence of suicidality or agitation for predicting suicide within 90 days or a repeat ED visit for self-harm within 30 days using retrospective data from all patients seen in an urban safety net ED over 27 months. Patients were assessed for suicidality using the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener and for agitation using either the Behavioral Activity Rating Scale or Richmond Agitation Sedation Scale. We hypothesized that a screener based on the presence of either suicidality or agitation would be more sensitive to suicide risk than the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. The screener's performance is described, and multivariable regression evaluates the correlations between screening and outcomes. The sample comprised 16,467 patients seen in the ED who had available suicide screening and agitation data. Thirteen patients (0.08%) died by suicide within 90 days after ED discharge. The sensitivity and specificity of the screener combining suicidality and agitation for predicting suicide was 0.69 (95% confidence interval, 0.44-0.94) and 0.74 (0.44-0.94), respectively. The sensitivity and specificity for agitation combined with positive suicide screening for self-harm within 30 days were 0.95 (0.89-1.00) and 0.73 (0.73-0.74). For both outcomes, augmenting the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener with a measure of agitation improved both sensitivity and overall performance compared to historical performance of the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. Combining a brief objective measure of agitation with a common suicide screening instrument improved sensitivity and predictive performance for suicide and self-harm risk after ED discharge. These findings speak to the importance of assessing agitation not only for imminent safety risk during the patient encounter but also for reducing the likelihood of future adverse events. This work can improve the detection and management of suicide risk in emergency settings.

Improving Access and Quality of Care for Kidney Stone Patients in an Underserved Community.

There is a call to improve Medicaid patient access to health care, enhance quality and outcomes of care, and reduce overall financial burden. We sought to build a comprehensive kidney stone program to help patients navigate through the acute and preventive aspects of stone disease by increasing multidisciplinary referrals and compliance with recommendations and decreasing no-show rates at first follow-up and repeat stone encounters after initial evaluation. A collaborative multidisciplinary program was established at our single institution consisting of urology, nephrology, and dietary specialists to be piloted over a 3-year period. Medicaid-designated patients were evaluated during new patient encounters by urology specialists and then followed for outpatient follow-up, including specialty referrals to nephrology specialists and dietitians, for targeted preventive measures. Subjective compliance reports by patients following interventions and no-show rates at subsequent follow-ups were documented. We also followed patients 6 months beyond the initial encounter to assess repeat Emergency Department (ED) visits for acute stone episodes. One hundred eighty-three Medicaid-designated stone patients were evaluated from 2018 to 2021. Sixty-eight percent of patients identified as White, 18% identified as Black/African American, and 14% identified as "Other." Patients underwent specialty referrals to nephrology or a dietician in 47% and 42% of cases, respectively. Since the program's implementation, reported patient compliance and referrals to multidisciplinary specialists increased from 72.9% to 81.30% and 21.2% to 56.20%, respectively. Repeat ED visits for stone-related encounters within 6 months of initial presentation remained relatively stable (from 17.60% to 18.9%), while no-show rates at first follow-up decreased from 20.0% to 6.30% by study conclusion. There is continued supporting evidence for the importance of a comprehensive kidney stone program specifically for patients of lower socioeconomic status following a 3-year implementation at our institution. Encouraging results indicate increased access to multidisciplinary specialty referrals, with improvement in follow-up and reported compliance related to stone prevention strategies.

2217. Sexually Transmitted Infection (STI) Therapy Compliance Pre and Post Centers for Disease Control and Prevention (CDC) STI Treatment Guideline Update

Abstract Background In December 2020, an update to the CDC STI Guidelines was published for the treatment of uncomplicated Neisseria gonorrhoeae (GC) and the common co-infection of Chlamydia trachomatis (CT). These prescribing changes reflect goals of antimicrobial stewardship and antimicrobial susceptibility. Previous studies assessed guideline prescribing adherence; however, there is no current literature to assess the impact of these updates. The results will be used to further evaluate the impact of the 2021 CDC STI Treatment Guidelines on prescribing patterns in the Emergency Department (ED). Methods This study was a single-center, retrospective cohort study which included patients treated for an STI (GC/CT) in the ED at an academic medical center between February 1, 2020 and August 31, 2021, &amp;gt; 19 years of age, and discharged from the ED. The primary endpoint is to determine if the updated guidelines contributed to a reduced incidence of appropriate guideline directed therapy for ED treatment of STIs. Secondary endpoints include ED patients still in need of STI treatment 30-days post-ED discharge, ED patients lost to follow-up within 30 days post-ED discharge and repeat ED visit for STI within 30 days. Results A total of 1049 patient encounters were screened for inclusion with 338 patient encounters in the Pre-CDC update cohort (PRE) and 346 patient encounters in the Post-CDC update cohort (POST). Results for the primary outcome indicate a statistically significantly reduced incidence of appropriate guideline directed therapy for ED treatment of STIs (PRE = 98.2% vs POST = 62.7%, p&amp;lt; 0.0001). Results for the secondary outcomes were not statistically significant. Conclusion The update to the CDC STI Treatment Guidelines led to decreased guideline directed therapy prescribing in an academic medical center ED. There was no difference in ED patients still needing treatment, lost to follow-up, or repeat ED visits for STI within 30 days post ED discharge. Disclosures All Authors: No reported disclosures.