Require Emergency Department Care Research Articles

Cost-Effectiveness of Bivalent Respiratory Syncytial Virus PrefusionF (RSVpreF) Vaccine During Pregnancy for Prevention of Respiratory Syncytial Virus Among Infants in Argentina.

Lower respiratory tract illness (LRTI) caused by respiratory syncytial virus (RSV) is common among young children in Argentina. Use of the currently available prophylactic agent is limited to children aged ≤ 2years with selected high-risk conditions, and thus the majority of infants remain unprotected. We estimated the value-based price (VBP) of a novel RSVpreF vaccine for use among pregnant people for prevention of RSV-LRTI among infants during the first year of life. Clinical outcomes and economic costs of RSV-LRTI during infancy and expected impact of RSVpreF vaccination during pregnancy were projected using a population-based Markov-type cohort model. Model results-estimated on the basis of gestational age at birth, disease/fatality rates, and mother's vaccination status-include total numbers of RSV-LRTI cases, RSV-LRTI-related deaths, and associated costs. Base case analyses (RSVpreF vs. no vaccine) were conducted from the healthcare system perspective. Probabilistic sensitivity analyses (PSA; 1000 replications) were also conducted. Willingness-to-pay (WTP) was $10,636 per quality-adjusted life-year (QALY; i.e., 1 × 2021 gross domestic product [GDP] per capita) in base case analyses and PSA. Costs are reported in USD, estimated on the basis of the June 22, 2023 exchange rate. Use of RSVpreF among 342,110 pregnant persons provided protection to 330,079 infants at birth. In total, RSVpreF prevented 3915 RSV hospitalizations, 6399 RSV cases requiring emergency department care, 6182 RSV cases requiring a physician office visit, and 67 disease-related deaths. Direct costs were projected to be reduced by $5.0million. With 2061 QALYs gained and vaccine administration cost of $1.4million, the VBP of RSVpreF was estimated to be $74.46 per dose. In PSA, mean VBP was $75.02 (95% confidence interval 54.24-97.30). RSVpreF among pregnant persons would significantly reduce the clinical and economic burden of RSV-LRTI among infants in Argentina and would be considered a cost-effective intervention up to a price of approximately $75.

Influence of type of household on prognosis at one year in patients ≥65years attending hospital emergency departments in Spain. The EDEN-6 study.

To investigate whether the type of household is associated with prognosis at one year in patients ≥65years of age discharged after medical consultation requiring emergency department care. Data from the Emergency Department and Elder Needs (EDEN) cohort were used. This retrospective cohort included all patients ≥65years of age seen in 52 Spanish emergency departments over one week (April 1-7, 2019) in whom the type of household was recorded and categorized as living at home alone, with relatives, with professional caregivers, or in a nursing home. Patient demographic and other baseline characteristics and management during the index emergency department episode were recorded and used to adjust the following 1-year outcomes: all-cause mortality, hospitalization and emergency department revisit. Associations between type of household and outcomes are expressed as adjusted hazard ratios with 95% confidence intervals using living alone as the reference category. 13,442 patients with a median age of 79years (interquartile range 72-86) were included; 56% were women, 12.2% of patients lived alone, 74.9% with relatives, 3.9% with a professional caregiver, and 9.1% in a nursing home. During the year following discharge, the mortality rate was 14.0%, the hospitalization rate 29.7%, and the emergency department revisit rate 59.3%. In the fully adjusted model, the risk of death was associated only with living in a nursing home (hazard ratio 1.366 (1.101-1.695)). On the other hand, the risk of hospitalization was lower in individuals living in nursing homes (hazard ratio 0.783 [0.676-0.907]) and at home with relatives (hazard ratio 0.897 [0.810-0.992]), while the risk of emergency department revisit was lower in individuals living in nursing homes (hazard ratio 0.826 [0.742-0.920]) or at home with caregivers (hazard ratio 0.856 [0.750-0.976]). The type of household was modestly associated with the one-year prognosis of patients ≥65years of age discharged after attendance at an emergency department. Living in a nursing home is associated with an increased risk of death but a decreased risk of rehospitalization or emergency department revisit, while living at home with relatives or professional caregivers is associated only with a decreased risk of hospitalization and emergency department revisit, respectively.

Rates and predictors of hospital and emergency department care after catheter ablation of atrial fibrillation.

Although atrial fibrillation (AF) ablation has become increasingly safer, rehospitalization and emergency department (ED) evaluations can occur in the postablation period. Better understanding of the frequency, causes, and predictors for hospitalization and ED evaluation after ablation are needed, particularly as same-day discharge programs expand. The Optum Clinformatics database was used to define rates, causes, and predictors of hospital and ED care after AF ablation performed between January 2016 and May 2019. Primary outcomes were all-cause hospital and ED care within 30 days of discharge. Independent predictors of all-cause ED and hospital admissions care were determined via logistic regression. Of the 18 848 patients in this study, the mean age was 67.5 ± 10 years, 37.9% were female, and the mean CHA2 DS2 -VASc score was 3.27 ± 1.84. Within 30 days of AF ablation, 1440 of 18 848 patients (7.6%) required hospital care of which 15% had >1 admission; 7.9% required ED care of which 28.6% had >1 ED visit. The most common reasons for hospital admission (which occurred on average 12.3 days after discharge) were supraventricular tachycardia (SVT) or AF (33.2%), heart failure (12.7%), and infection (12.2%). The most common reasons for ED care were SVT/AF (15.0%), noncardiac chest pain (13.3%), and noninfectious respiratory illness (12.2%). Age, female sex, ablation in an inpatient setting, and co-morbidities were associated with increased risk of rehospitalization. Age, female sex, patient comorbidities, and non-use of direct oral anticoagulation were associated with increased risk of ED visit. Approximately 7%-8% of patients require unplanned hospitalization or ED care after AF ablation, most commonly due to SVT/AF. Predictors of unscheduled care include patient age, sex, and several patient comorbidities. This study can inform quality improvement initiatives by identifying common causes for unscheduled care.

Clinical outcomes of children and adolescents with sickle cell disease and COVID-19 infection: A year in review at a metropolitan tertiary pediatric hospital.

COVID-19 was declared a global pandemic in March 2020. Early reports were primarily in adults, and sickle cell disease (SCD) was classified as a risk factor for severe COVID-19 disease. However, there are a limited number of primarily multi-center studies reporting on the clinical course of pediatric patients with SCD and COVID-19. We conducted an observational study of all patients with SCD diagnosed with COVID-19 at our institution between March 31, 2020, and February 12, 2021. Demographic and clinical characteristics of this group were collected by retrospective chart review. A total of 55 patients were studied, including 38 children and 17 adolescents. Demographics, acute COVID-19 clinical presentation, respiratory support, laboratory findings, healthcare utilization, and SCD modifying therapies were comparable between the children and adolescents. Seventy-three percent (N = 40) of all patients required emergency department care or hospitalization. While 47% (N = 26) were hospitalized, only 5% (N = 3) of all patients required intensive care unit admission. Patients frequently had concurrent vaso-occlusive pain crisis (VOC) (N = 17, 43%) and acute chest syndrome (ACS) (N = 14, 35%). Those with ACS or an oxygen requirement had significantly higher white blood cell count, lower nadir hemoglobin, and higher D-dimers, supporting a pro-inflammatory and coagulopathic picture. Non-hospitalized patients were more likely to be on hydroxyurea than hospitalized patients (79 vs. 50%, p = 0.023). Children and adolescent patients with SCD and acute COVID-19 often present with ACS and VOC pain requiring hospital-level care. Hydroxyurea treatment appears to be protective. We observed no mortality despite variable morbidity.

Patient and physician factors associated with symptomatic undiagnosed asthma or COPD.

It remains unclear why some symptomatic individuals with asthma or COPD remain undiagnosed. Here, we compare patient and physician characteristics between symptomatic individuals with obstructive lung disease (OLD) who are undiagnosed and individuals with physician-diagnosed OLD. Using random-digit dialling and population-based case finding, we recruited 451 participants with symptomatic undiagnosed OLD and 205 symptomatic control participants with physician-diagnosed OLD. Data on symptoms, quality of life and healthcare utilisation were analysed. We surveyed family physicians of participants in both groups to elucidate differences in physician practices that could contribute to undiagnosed OLD. Participants with undiagnosed OLD had lower mean pre-bronchodilator forced expiratory volume in 1 s percentage predicted compared with those who were diagnosed (75.2% versus 80.8%; OR 0.975, 95% CI 0.963-0.987). They reported greater psychosocial impacts due to symptoms and worse energy and fatigue than those with diagnosed OLD. Undiagnosed OLD was more common in participants whose family physicians were practising for >15 years and in those whose physicians reported that they were likely to prescribe respiratory medications without doing spirometry. Undiagnosed OLD was more common among participants who had never undergone spirometry (OR 10.83, 95% CI 6.18-18.98) or who were never referred to a specialist (OR 5.92, 95% CI 3.58-9.77). Undiagnosed OLD was less common among participants who had required emergency department care (OR 0.44, 95% CI 0.20-0.97). Individuals with symptomatic undiagnosed OLD have worse pre-bronchodilator lung function and present with greater psychosocial impacts on quality of life compared with their diagnosed counterparts. They were less likely to have received appropriate investigations and specialist referral for their respiratory symptoms.

Emergency department visits for vaccine-related severe allergic reactions among US adults: 2006-2018

Emergency department visits for vaccine-related severe allergic reactions among US adults: 2006-2018

Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients

Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED). We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing. Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types-especially therapists, radiologists, and pathologists, as well as hand surgeons-was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing. Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues. Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.

Pediatric Emergency Department Management of C1 Inhibitor Deficiency.

C1 inhibitor deficiency is a rare, potentially life-threatening syndrome. Acute attacks of angioedema may occur at any time, so the emergency department (ED) constitutes an indispensable component of its care. To describe the reasons for consultation by children with C1 inhibitor deficiency at the ED, as well as its management and complications. This is a longitudinal retrospective study conducted in a pediatric ED of a tertiary care hospital in Madrid. The study includes children with C1 inhibitor deficiency, aged 0 to 16 years, who had consulted the ED for whatever reason, over a span of 9 years (2011-2020). Analyzed data include the following: age, sex, type of disease, reason for query, complementary examinations, established diagnosis, treatment, number of visits to the ED, length of ED stay, and admissions. Sixteen patients, amounting a total of 83 ED visits, were analyzed. Fifty-six percent were boys, and the median age was 6.9 years (5 months to 15.9 years). The median and mean of number of visits to the ED per patient was 2 (1-22) and 5.2 ± 6.11, respectively. There were 85.5% of the ED visits initially attributed to acute angioedema attacks. Additional tests were conducted in 30.1%, and 31.3% required C1 inhibitor concentrate. Three episodes required hospital admission (3.6%), and there were no complications. The stay in the ED was longer for patients who needed specific intravenous treatment. C1 inhibitor deficiency is a rare disease that may require ED care. The main reasons for ED visits were respiratory problems, and the main location of the acute attacks of angioedema were abdominal and cutaneous. Almost one third of the ED visits needed specific treatment, resulting in longer stays. A proper management in the ED and the specific treatment with C1 inhibitor concentrate were effective in 96.2% of the acute attacks of angioedema. Knowledge of this disease in the ED is key to prevent complications.

Novel treatment of dihydrogen sulfide inhalation using hyperbaric oxygen during mass casualty

Hydrogen sulfide (H2S) is a toxic gas produced via breakdown of organic matter. Hydrogen sulfide exposure can cause symptoms ranging in severity from mild effects (dizziness, headache, nausea) to severe lactic acidosis, respiratory failure, pulmonary edema, cardiac arrhythmias and death. Treatment modalities include oral countermeasures and 100% FiO2 with supportive therapy. However, case studies utilizing hyperbaric oxygen (HBO2) therapy have been reported with general benefit seen in severe cases of toxicity. In this report, cases of mild to moderate H2S toxicity occurred aboard a U.S. Navy ship, resulting in a mass casualty incident of more than 30 patients. Patient symptoms included dizziness, headaches, nausea, vomiting, and one patient with altered mental status. Most patients’ symptoms resolved after several hours of supportive therapy, but six patients had symptoms refractory to 100% FiO2 at 1 atm. These six patients received HBO2 therapy with a USN Treatment Table 9 after consultation with the local emergency room and hyperbaric assets. Four separate chambers were utilized, including two chambers onboard USN ships and the local explosive ordnance disposal (EOD) chamber. Complete resolution of symptoms in all six patients was achieved within the first breathing period. Patients were monitored after treatment aboard the USN ship medical department. No patients required emergency department care. These cases demonstrate an expanded use of HBO2 to include moderate cases of H2S toxicity refractory to first-line therapy.

Patient Reported Outcomes Among Systemic Mastocytosis (SM) Patients in Routine Clinical Practice: Results from the TouchStone Survey

Introduction: SM is a rare, clonal mast cell neoplasm characterized by uncontrolled proliferation and activation of mast cells driven by the KIT D816V mutation, which leads to severe and unpredictable symptoms. This study evaluated disease and healthcare system burden of SM in a real-world treatment setting in the US. Methods: In this cross-sectional study, SM patients recruited through the Mast Cell Connect Registry completed an online survey. The 100-item survey consists of symptom assessments using the ISM-SAF© and widely used patient-reported outcomes (PRO) measures including the Short Form (SF)-12, Work Productivity and Activity Impairment (WPAI), and questions regarding SM-related medication and physician and emergency department (ED) visits during the past year. Patients ≥18 years with a self-reported diagnosis were included after providing informed consent. Established PRO measures were scored using established scoring algorithms. Data from the first 30 patients enrolled were analyzed using descriptive statistics. Results: Thirty patients completed the survey: 87% female; mean age of 54 years; mean time since diagnosis of 8 years; mean time from symptom onset to diagnosis of 7 years; 80% reported indolent SM, 10% reported aggressive SM, 3% reported smoldering SM, and the remainder (7%) were uncertain of their type. Ninety percent reported ≥10 symptoms during the past year, the most bothersome being abdominal/stomach pain (17%), anaphylactic episodes (13%), diarrhea/loose stools (13%), and fatigue (10%). Most patients indicated they have moderate (43%) or severe (33%) disease. Symptom Burden and Quality of Life (QoL) Impact Mean ± SD mental and physical component summary scores from the SF-12 were 44 ± 1.8 and 43 ± 2.5, respectively, indicating below average health and mental well-being. The mean total symptom score (TSS) from the ISM-SAF was 50, with >28 indicating moderate-severe SM. Nearly all (27/30) patients reported that they strongly agreed (27%), agreed (40%) or somewhat agreed (23%) that SM had a negative impact on their QoL, and 50% (15/30) reported feeling a great deal (17%), quite a bit (10%), or somewhat (23%) depressed or discouraged due to their disease. Use of Healthcare Services & Medications Patients reported encounters with multiple physicians over the course of 1 year (Table). Most patients (90%) reported taking ≥2 over-the-counter (OTC) medications, and 40% of patients reported taking >3 prescription medications to manage SM. Twenty percent of survey respondents visited the ED due to anaphylaxis, with 50% of these patients requiring ED care for anaphylaxis on 3 different occasions. Fifty-seven percent (17/30) of patients reported managing at least 1 anaphylactic episode at home without visiting the ED, with 4 of these patients reporting ≥12 anaphylactic episodes within the past year. Work Impairment Limited activities due to pain attributed to SM were reported by 60% (18/30) of patients, and 56% (17/30) of patients indicated that pain interfered with their ability to work. 17% of respondents reported they were unable to work for pay, 46% of patients reported having to reduce work hours because of SM, and 20% of patients had filed for disability, all due to SM. Conclusions: Despite close management by healthcare providers, and taking prescription and OTC medications, early findings from the TouchStone survey show that the majority of SM patients continue to report significant burden of disease, including inadequate symptom control, negative effects on QoL, reduced ability to work, frequent physician visits to manage SM and multiple, potentially costly, ED visits. These findings suggest high unmet medical need underscoring the value of more effective therapeutic interventions. Disclosures Mesa: LaJolla Pharma: Consultancy; Novartis: Consultancy; Sierra Onc: Consultancy; Abbvie: Research Funding; Celgene: Research Funding; CTI: Research Funding; Genetech: Research Funding; Incyte: Research Funding; Promedior: Research Funding; Samus: Research Funding. Sullivan:Blueprint Medicines Corporation: Current Employment, Current equity holder in publicly-traded company. Dubinsky:Blueprint Medicines Corporation: Current Employment, Current equity holder in publicly-traded company. Carroll:Blueprint Medicines Corporation: Consultancy, Current equity holder in publicly-traded company. Mathias:Blueprint Medicines Corporation: Other: employed by Health Outcomes Solutions, which received funding Blueprint for providing assistance in developing the Touchstone survey. Castells:Annals of Allergy, Asthma & Immunology: Other: Editorial Board; UpToDate: Other: Author fee; Blueprint Medicines Corporation: Consultancy, Other: Clinical trials: Principle Investigator.

When Child Neglect Is an Emergency

Neglect is the most prevalent form of child maltreatment. Neglect can lead to serious medical issues requiring emergency department care including injuries, ingestions, decompensation of chronic illnesses, and urgent behavioral health concerns. Knowledge of different types of neglect, and of how each type could result in an emergency department (ED) visit could help clinicians to recognize and respond to neglect. This review will outline supervisory, medical, dental, emotional, and physical neglect. Children could also present to the ED for evaluation after a substantiated report for neglect. Therefore, this review also covers important elements of medical evaluations for children who have experienced neglect. Neglect is the most common reason for foster care placement, and considerations for emergency medicine providers caring for children in foster care are outlined. Avenues for prevention of neglect in the ED setting are also discussed.

LO20: The characteristics, clinical course and disposition of long-term care patients treated by paramedics during an emergency call: Exploring the potential impact of community paramedicine

Introduction: An increasing number of Canadian paramedic services are creating Community Paramedic programs targeting treatment of long-term care (LTC) patients on-site. We explored the characteristics, clinical course and disposition of LTC patients cared for by paramedics during an emergency call, and the possible impact of Community Paramedic programs. Methods: We completed a health records review of paramedic call reports and emergency department (ED) records between April 1, 2016 and March 31, 2017. We utilized paramedic dispatch data to identify emergency calls originating from LTC centers resulting in transport to one of the two EDs of the Ottawa Hospital. We excluded patients with absent vital signs, a Canadian Triage and Acuity Scale (CTAS) score of 1, and whose transfer to hospital were deferrable or scheduled. We stratified remaining cases by month and selected cases using a random number generator to meet our apriori sample size. We collected data using a piloted standardized form. We used descriptive statistics and categorized patients into groups based on the ED care received and if the treatment received fit into current paramedic medical directives. Results: Characteristics of the 381 included patients were mean age 82.5 years, 58.5% female, 59.7% hypertension, 52.6% dementia and 52.1% cardiovascular disease. On arrival at hospital, 57.7% of patients waited in offload delay for a median time of 45 minutes (IQR 33.5-78.0). We could identify 4 groups: 1) Patients requiring no treatment or diagnostics in the ED (7.9%); 2) Patients receiving ED treatment within current paramedic medical directives and no diagnostics (3.2%); 3) Patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and 4) patients requiring admission (34.1%). Most patients were discharged from the ED (65.6%), and 1.1% died. The main ED diagnoses were infection (18.6%) and musculoskeletal injury (17.9%). Of the patients that required ED care but were discharged, 64.1% required x-rays, 42.1% CT, and 3.4% ultrasound. ED care included intravenous fluids (35.7%), medication (67.5%), antibiotics (29.4%), non-opioid analgesics (29.4%) and opioids (20.7%). Overall, 11.1% of patients didn't need management beyond current paramedic capabilities. Conclusion: Many LTC patients could receive care by paramedics on-site within current medical directives and avoid a transfer to the ED. This group could potentially grow using Community Paramedics with an expanded scope of practice.

Postpartum complications in women attended by midwives instead of obstetricians

ObjectiveThe aim of this study was to evaluate changes in the frequency of visits to the hospital emergency department due to puerperal complications in low risk postpartum women attended by midwives instead of obstetricians. DesignA quasi-experimental retrospective study with non-random allocation, comprising two groups: a control group of women attended by obstetricians and an intervention group of women attended by midwives. SettingA level 2 hospital in Madrid (España). ParticipantsLow risk postpartum women attended at the maternity unit of the Fuenlabrada University Hospital between 2013 and 2015. MethodsWe gathered variables to record the homogeneity of the groups and to assess for confounders and interactions. In the case of women with different behaviours and/or who generated confounders or interactions, a multivariate adjustment with logistic regression was performed. The Homer & Lemeshow goodness-of-fit test for logistic regression was used to determine the validity of the model. Measurements and findingsThe intervention group comprised a total of 1308 women, whereas there were 1313 women in the control group. In the first 40-days postpartum, 33 women in the intervention group (2.5%) attended the hospital emergency department compared to 41 in the control group (3.1%). This difference was not statistically significant (p value 0.354). The relative risk of this decrease was 0.808 (95% CI 0.514; 1.270). The NNT was 167. Key conclusions and implications for practiceCare by midwives of low risk postpartum women did not lead to a worsening of puerperal complications requiring emergency department care. Furthermore, care by midwives was more effective than obstetrician care with lower emergency department attendance rates. Their qualification and capacity to provide health education were determinant factors.

The association of continuity of care and cancer centre affiliation with outcomes among patients with cancer who require emergency department care.

Patients with cancer have complex care requirements and frequently use the emergency department. The purpose of this study was to determine whether continuity of care, cancer expertise of an institution or both affect outcomes in patients with cancer in the emergency setting. We conducted a retrospective cohort study using administrative databases from Ontario, Canada, involving records of patients aged 20 years and older who received chemotherapy or radiation in the 30 days before a cancer-related visit to the emergency department between 2006 and 2011. Patients seen in an emergency department at an alternative hospital (not the site where cancer treatment was given) were matched based on propensity score to patients who visited their original hospital (site where cancer treatment was given). Next, patients seen at an alternative emergency department that was in a general hospital (i.e., not a cancer centre) were matched to patients who visited their original hospital or a cancer centre. Outcomes were admission to hospital at the index visit to the emergency department, 30-day mortality, having imaging with computed tomography and return visits to the emergency department. We found 42 820 patients who were eligible for our study. Patients seen in the emergency departments at alternative hospitals were less likely to be admitted to hospital (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.74-0.83) and had higher hazards of return visits to the emergency department than matched patients at original hospitals (hazard ratio [HR] 1.06, 95% CI 1.03-1.11). In comparison, patients at alternative general hospitals also had lower odds of admission to hospital (OR 0.83, 95% CI 0.79-0.88) and higher hazards of return visits to the emergency department (HR 1.07, 95% CI 1.03-1.11) compared with matched counterparts; however, these patients had higher 30-day mortality (OR 1.13, 95% CI 1.05-1.22) and lower odds of having CT imaging (OR 0.74, 95% CI 0.69-0.80). Cancer expertise of an institution rather than continuity of care may be an important predictor of outcomes following emergency treatment of patients with cancer.

716. Molecular Epidemiology of Respiratory Syncytial Virus in Children and Adults in Seattle, WA

BackgroundRespiratory syncytial virus (RSV) is the most important cause of pneumonia in children <5 years worldwide and may cause severe disease in elderly and high-risk adults. Multiple RSV strains co-circulate and evolve over seasons. We seek to describe the evolution of RSV over five seasons in Seattle, WA, USA with two seasons reported here.MethodsFrom 2014 to 2016, subjects 6 months and older seeking outpatient care for acute respiratory illness at Kaiser Permanente Washington were enrolled in the Influenza Vaccine Efficacy Network (Flu VE Network) and a respiratory swab was collected. Real-time polymerase chain reaction (RT-PCR) was performed to test and quantify RSV and subtype positive samples. A subset of RSV samples with cycle threshold (CT) value <30 will be sequenced using a metagenomic next-generation sequencing (NGS) approach. Specific RSV genotypes will be associated with severe disease, defined as requiring emergency department care or hospitalization, or chest radiographic findings.ResultsA total of 8,730 patients were enrolled in the Flu VE Network and PCR testing of seasons 2014/2015 and 2015/2016 resulted in 562 of 4,137 (13.6%) RSV-positive specimens. Of patients with RSV-positive specimens, 204 (36.5%) were adults 18–64 years and 112 (20.0%) were 65+ years. RSV-B predominated in the 2014/2015 season (n = 298; 83.7%), whereas RSV-A was more common in the 2015/2016 season (n = 154; 79.8%) (Figure 1). The median (IQR) CT value for RSV-A specimens was 26.7 (23.3–29.9) compared with 27.9 (25.2–31.3) for RSV-B.ConclusionOne RSV subtype predominated within each season. Similar RSV subtype distributions were seen across age categories. With multiple RSV vaccine candidates in development, understanding the genetic diversity and circulation of RSV various viruses within a population is important for analyzing the effects of a vaccine on the evolution of RSV. Figure 1, Total counts (A) and proportions (B) of RSV-A and RSV-B specimens collected from study patients in Seattle, WA during 2014/2015 and 2015/2016 seasons, by age category.Disclosures M. L. Jackson, sanofi pasteur: Grant Investigator, Research support. H. Chu, Sanofi-Pasteur: Grant Investigator, Grant recipient.

Overall Approach to Trauma in the Emergency Department.

1. Daniel M. Fein, MD* 2. Michele J. Fagan, MD† 1. *Division of Pediatric Emergency Medicine, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY 2. †Division of Pediatric Emergency Medicine, Maimonides Infants and Children’s Hospital, Brooklyn, NY * Abbreviations: ABCs: : Airway, Breathing, and Circulation ATLS®: : Advanced Trauma Life Support® BSA: : body surface area CSF: : cerebrospinal fluid EMS: : emergency medical services FAST: : Focused Assessment with Sonography for Trauma GCS: : Glasgow Coma Scale MVA: : motor vehicle accident TBI: : traumatic brain injury Assessing a child who has sustained a multisystem trauma requires a structured assessment of the airway, breathing, and circulation to promptly identify life-threatening injuries and allow for timely lifesaving interventions. This is followed by a more detailed evaluation of the entire body to evaluate for all injuries. After completing this article, readers should be able to: 1. Identify the steps of the primary and secondary surveys used during evaluation of a child who has sustained trauma. 2. Describe the potential life-threatening injuries that may occur after trauma and their treatment. 3. Understand the evaluation and management of a child who has sustained a significant burn. The importance of trauma in children is readily apparent in that injury is the leading cause of death and disability in children from infancy to young adulthood in the United States. Each year, more than 9,000 children die of serious injury, and approximately 8.7 million children require emergency department care for treatment of their injuries. (1) This surpasses all major diseases in children and young adults. Specifically, motor vehicle accidents (MVAs) are 1 of the top 2 causes of death in children of all age groups. Childhood injuries result in costs exceeding $87 billion annually (1) when accounting for direct medical costs as well as costs to the economy, cost of rehabilitation, and costs to the families of children who survive childhood injury but have resultant lifelong disabilities. Childhood injury is a public health problem that has multiple facets, ranging from injury prevention to rehabilitation and reintegration into society. The American College of Surgeons created the Advanced Trauma Life Support® (ATLS®) course to help train physicians to face …

Management practice-related and modifiable factors associated with paediatric emergency return visits.

We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED). We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors. There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process. Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.

Emergency Department as a First Contact for Mental Health Problems in Children and Youth

To characterize youth who use the emergency department (ED) as a "first contact" for mental health (MH) problems. This was a population-based cross-sectional cohort study using linked health and demographic administrative datasets of youth 10 to 24 years of age with an incident MH ED visit from April 1, 2010, to March 31, 2014, in Ontario, Canada. We modeled the association of demographic, clinical, and health service use characteristics with having no prior outpatient MH care in the preceding 2-year period ("first contact") using modified Poisson models. Among 118,851 youth with an incident mental health ED visit, 14.0% were admitted. More than half (53.5%) had no prior outpatient MH care, and this was associated with younger age (14-17 versus 22-24 years old: risk ratio [RR]= 1.09, 95% CI=1.07-1.10), rural residence (RR= 1.16, 95% CI=1.14-1.18), lowest versus highest income quintile (RR= 1.04, 95% CI= 1.03-1.06), and refugee immigrants (RR= 1.17, 95% CI= 1.13-1.21) and other immigrants (RR= 1.10, 95% CI= 1.08-1.13) versus nonimmigrants. The 5.1% of the cohort without a usual provider of primary care had the highest risk of first contact (RR=1.78, 95% CI= 1.77-1.80). A history of low-acuity ED use and individuals whose primary care physicians were in the lowest tertile for mental health visit volumes were associated with higher risk. More than half of youth requiring ED care had not previously sought outpatient MH care. Associations with multiple markers of primary care access characteristics suggest that timely primary care could prevent some of these visits.

Traumatic Facial Injuries Among Elderly Nursing Home Residents

As the nursing home population continues to increase, an understanding of preventable injuries becomes exceedingly important. Although other fall-related injuries have been characterized, little attention has been dedicated to facial trauma. To estimate the incidence of facial trauma among nursing home residents and detail mechanisms of injury, injury characteristics, and patient demographic data. The National Electronic Injury Surveillance System was used to calculate a weighted national incidence of facial trauma among individuals older than 60 years from a nationally representative collection of emergency departments from January 1, 2011, through December 31, 2015. Entries were screened for nursing home residents, and diagnosis, anatomical site, demographic data, and mechanism of injury were analyzed. There were 109 795 nursing home residents (median age, 84.1 years; interquartile range, 79-89 years; 71 466 women [65.1%]) who required emergency department care for facial trauma. Women sustained a greater proportion of injuries with increasing age. The most common injuries were lacerations (48 679 [44.3%]), other soft-tissue injuries (45 911 [41.8%]; avulsions, contusions, and hematomas), and fractures (13 814 [12.6%]). Nasal (9331 [67.5%]) and orbital (1144 [8.3%]) fractures were the most common sites. The most common injury causes were direct contact with structural housing elements or fixed items (62 604 [57.0%]) and transfer to and from bed (24 870 [22.6%]). Despite falls being considered a Centers for Medicare & Medicaid Services preventable never event in hospitals, our analysis in the nursing home setting found more than 100 000 facial injuries during 5 years, suggesting these underappreciated injuries contribute substantially to health care expenditures. Although structural elements facilitated the greatest number of falls, transfer to and from bed remains a significant mechanism, suggesting an area for intervention.

Urban Bicyclist Trauma: Characterizing the Injuries, Consequent Surgeries, and Essential Sub-Specialties Providing Care

In the United States in 2013, nearly 500,000 bicyclists were injured and required emergency department care. The objectives of this study were to describe the types of injuries which urban bicyclists sustain, to analyze the number and type of surgeries required, and to better delineate the services providing care. This is an observational study of injured bicyclists presenting to a Level I trauma center between February 2012 and August 2014. Most data were collected within 24 hours of injury and included demographics, narrative description of the incident, results of initial imaging studies, Injury Severity Score, admission status, length of stay, surgical procedure, and admitting and discharging service. A total of 706 injured bicyclists were included in the study, and 187 bicyclists (26.4%) required hospital admission. Of those admitted, 69 (36.8%) required surgery. There was no difference in gender between those who required surgery and those who did not (P = 0.781). Those who required surgery were older (mean age 39.1 vs 34.1, P = 0.003). Patients requiring surgery had higher Abbreviated Injury Scores for head (P ≤ 0.001), face (P ≤ 0.001), abdomen (P = 0.012), and extremity (P ≤ 0.001) and higher mean Injury Severity Scores (12.6 vs 3.7, P < 0.001). Sixty-nine patients required surgery and were brought to the operating room 82 times for 89 distinct procedures. Lower extremity injuries were the reason for 43 (48.3%) procedures, upper extremity injuries for 14 (15.7%), and facial injuries for 15 (16.9%). Orthopedic surgery performed 50 (56.2%) procedures, followed by plastic surgery (15 procedures; 16.8%). Trauma surgeons performed five (5.6%) procedures in four patients. The majority of admitted patients were admitted and discharged by the trauma service (70.1%, 56.7%, respectively) followed by the orthopedics service (13.9%, 19.8%, respectively). Injured bicyclists represent a unique subset of trauma patients. Orthopedic surgeons are most commonly involved in their operative management and rarely are the operative skills of a general traumatologist required. From a resource perspective, it is more efficient to direct the inpatient care of bicyclists with single-system trauma to the appropriate surgical subspecialty service soon after appropriate initial evaluation and treatment by the trauma service.