Subsequent Hospital Admission Research Articles

Diversion of hospital admissions from the emergency department using an interprofessional team: a propensity score analysis.

To examine if an ED interprofessional team ("ED1Team") could safely decrease hospital admissions among older persons. This single-center, retrospective, propensity score matched study was performed at a single ED during a control (December 2/2018-March 31/2019) and intervention (December 2/2019-March 31/2020) period. The intervention was assessed by the ED1Team, which could include an occupational therapist, physiotherapist, and social worker. We compared admission rates between period in persons age ≥ 70years. Next, we compared visits attended by the ED1Team to (a) control period visits, and (b) intervention period visits without ED1Team attendance. ED length-of-stay, 7-day subsequent hospital admission and mortality in discharged patients. There were 5496 and 4876 eligible ED visits during the control and intervention periods, respectively. In the latter group, 556 (11.4%) received ED1Team assessment. After matching, there was an absolute 2.3% (p = 0.07) reduction in the admission rate between control and intervention periods. After matching the 556 ED1Team attended visits to control period visits, and to intervention period visits without the intervention, admission rates decreased by 10.0% (p = 0.006) and 13.5% (p < 0.001), respectively. For discharged patients, median ED length-of-stay decreased by 1.0h (p < 0.001) between control and intervention periods and increased by 2.3h (p < 0.001) compared to intervention period without the intervention. For patients discharged by the ED1Team, subsequent readmissions after 7days were slightly higher, but mortality was not significantly different. ED1Team consultation was associated with a decreased hospital admission rate in older ED patients. It was associated with a slightly longer ED length-of-stay and subsequent early hospitalizations. Given that even a small increase in freed hospital beds would release some of the pressure on an overextended healthcare system, these results suggest that upscaling of the intervention might procure systems-wide benefits.

Patterns of antidepressant prescribing and health-related outcomes among older adults in Northern Ireland: an administrative data study

Objectives This study identifies patterns of antidepressant prescribing and subsequent hospital admissions from 2010 to 2018 amongst older adults in Northern Ireland (NI). Method Participants comprised all General Practitioner (GP)-registered adults aged fifty-five years and above on 01/01/2010 (n = 386,119). Administrative data linkage included demographic information; antidepressant prescribing data from the NI Enhanced Prescribing Database (EPD); and hospital patient admissions. Repeated measures latent class analysis (RMLCA) identified patterns of antidepressant prescribing (from 2010 to 2018). Results RMLCA identified four latent classes: decreasing antidepressant prescribing (5.9%); increasing antidepressant prescribing (8.0%); no-antidepressant prescribing (68.7%); and long-term antidepressant prescribing (17.5%). Compared with those in no-antidepressant prescribing class, persons in the remaining classes were more likely to be female and younger, and less likely to live in either rural areas or less-deprived areas. Compared with no-antidepressant prescribing, those with increasing antidepressant prescribing were 60% and 52% more likely to be admitted to hospital in 2019 and 2020, respectively, and their admission rate per year was 11% and 8% higher in 2019 and 2020, respectively. Similarly, those with long-term prescriptions were 70% and 67% more likely to be admitted to hospital in 2019 and 2020, respectively, and their admission rate per year was 14% and 9% higher in 2019 and 2020, respectively. Conclusion Findings show that approximately 26% of the NI hospital admissions population were impacted by sustained or increasing antidepressant prescribing. Because of their increased likelihood of hospitalization, these individuals may benefit from psychosocial support and social prescribing alternatives to psychopharmacological treatment.

Analysis of traumatic event emergency department visits among care home residents aged 65 + years in Southern Jutland, Denmark: implications for comprehensive care and subsequent hospital admissions - a register-based cohort study

BackgroundCare home residents aged 65 + years frequently experience acute health issues, leading to emergency department visits. Falls and associated injuries are a common cause of these visits and falls in a geriatric population can be a symptom of an incipient acute illness such as infection. Conversely, the traumatic event can cause illnesses to arise due to consequences of the fall, e.g. delirium or constipation due to opioid use. We hypothesised that a traumatic event treat-and-release emergency department visit serves as an indicator for an upcoming acute hospital admission due to non-trauma-related conditions.MethodsWe studied emergency department visits for traumatic events among all care home residents aged 65+ (n = 2601) living in Southern Jutland, Denmark, from 2018 to 2019. Data from highly valid national registers were used to evaluate diagnoses, mortality, and admissions. Cox Regression was used to analyse the hazard of acute hospital admission following an emergency department treat-and-release visit.ResultsMost visits occurred on weekdays and during day shifts, and 72.0% were treated and released within 6 h. Contusions, open wounds, and femur fractures were the most common discharge diagnoses, accounting for 53.3% of all cases (n = 703). In-hospital mortality was 2.3%, and 30-day mortality was 10.4%. Among treat-and-release visits (n = 506), 25% resulted in a new hospital referral within 30 days, hereof 13% treat-and-release revisits (duration ≤ 6 h), and 12% hospital admissions (duration > 6 h). Over half (56%) of new hospital referrals were initiated within the first seven days of discharge. Almost three-fourths of subsequent admissions were caused by various diseases. The hazard ratio of acute hospital admissions was 2.20 (95% CI: 1.52–3.17) among residents with a recent traumatic event treat-and-release visit compared to residents with no recent traumatic event treat-and-release visit.ConclusionTraumatic event treat-and-release visits among care home residents serve as an indicator for subsequent hospitalisations, highlighting the need for a more comprehensive evaluation, even for minor injuries. These findings have implications for improving care, continuity, and resource utilisation.Trial registrationNot relevant.

The association between sodium glucose cotransporter-2 inhibitors vs dipeptidyl peptidase-4 inhibitors and renal outcomes in people discharged from hospital with type 2 diabetes: A population-based cohort study.

We investigated the association between post-hospital discharge use of sodium glucose cotransporter-2 inhibitors (SGLT-2is) compared to dipeptidyl peptidase-4 inhibitors (DPP-4is) and the incidence of hospitalization for acute renal failure (ARF) and chronic kidney disease (CKD) in people with type 2 diabetes. We conducted a retrospective cohort study using linked hospital and prescription data. Our cohort included people aged ≥30 years with type 2 diabetes discharged from a hospital in Victoria, Australia, from December 2013 to June 2018. We compared new users of SGLT-2is with new users of DPP-4is following discharge. People were followed from first dispensing of a SGLT-2i or DPP-4i to a subsequent hospital admission for ARF or CKD. We used competing risk models with inverse probability of treatment weighting (IPTW) to estimate subhazard ratios. In total, 9620 people initiated SGLT-2is and 9962 initiated DPP-4is. The incidence rate of ARF was 12.3 per 1000 person-years (median years of follow-up [interquartile range [IQR] 1.4 [0.7-2.2]) among SGLT-2i initiators and 18.9 per 1000 person-years (median years of follow-up [IQR] 1.7 [0.8-2.6]) among DPP-4i initiators (adjusted subhazard ratio with IPTW 0.78; 95% confidence interval [CI] 0.70-0.86). The incidence rate of CKD was 6.0 per 1000 person-years (median years of follow-up [IQR] 1.4 [0.7-2.2]) among SGLT-2i initiators and 8.9 per 1000 person-years (median years of follow-up [IQR] 1.7 [0.8-2.6]) among DPP-4i initiators (adjusted subhazard ratio with IPTW 0.83; 95% CI 0.73-0.94). Real-world data support using SGLT-2is over DPP-4is for preventing acute and chronic renal events in people with type 2 diabetes.

Prediction Models Using Decision Tree and Logistic Regression Method for Predicting Hospital Revisits in Peritoneal Dialysis Patients.

Hospital revisits significantly contribute to financial burden. Therefore, developing strategies to reduce hospital revisits is crucial for alleviating the economic impacts. However, this critical issue among peritoneal dialysis (PD) patients has not been explored in previous research. This single-center retrospective study, conducted at Chang Gung Memorial Hospital, Chiayi branch, included 1373 PD patients who visited the emergency room (ER) between Jan 2002 and May 2018. The objective was to predict hospital revisits, categorized into 72-h ER revisits and 14-day readmissions. Of the 1373 patients, 880 patients visiting the ER without subsequent hospital admission were analyzed to predict 72-h ER revisits. The remaining 493 patients, who were admitted to the hospital, were studied to predict 14-day readmissions. Logistic regression and decision tree methods were employed as prediction models. For the 72-h ER revisit study, 880 PD patients had a revisit rate of 14%. Both logistic regression and decision tree models demonstrated a similar performance. Furthermore, the logistic regression model identified coronary heart disease as an important predictor. For 14-day readmissions, 493 PD patients had a readmission rate of 6.1%. The decision tree model outperformed the logistic model with an area under the curve value of 79.4%. Additionally, a high-risk group was identified with a 36.4% readmission rate, comprising individuals aged 41 to 47 years old with a low alanine transaminase level ≤15 units per liter. In conclusion, we present a study using regression and decision tree models to predict hospital revisits in PD patients, aiding physicians in clinical judgment and improving care.

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.

Requests, Issuing, and Hospital Admissions Regarding Mental Health Warrants Before and During the COVID-19 Pandemic in a Region in Portugal.

Mental health warrants exist in most countries and are issued when patients have severe mental illness, refuse treatment, and present a serious risk to themselves or others. We describe the epidemiology of mental health warrant requests received, and warrants issued by a Public Health Unit in a Portuguese region, as well as subsequent hospital admissions before and during the COVID-19 pandemic. We used routine administrative data of mental health warrant request entries from a Public Health Unit serving a population of 219 739 individuals and compared the average of monthly requests, issued warrants, and hospital admissions during two separate periods (January 2013 to January 2021 and February 2021 to October 2022) as well as the proportion of warrants issued, hospital admissions among requests, and other patient characteristics. We identified factors associated with hospital admissions among the requests using logistic regression. Monthly average warrant requests, issued warrants and hospital admissions increased after February 2021 (x̄ 2.87 vs 7.09 p < 0.001; x̄ 2.67 vs 6.42 p < 0.001; x̄ 1.55 vs 3.58 p < 0.001). We found no differences by period in the proportion of requests with issued warrants (92.8% vs 90.6% p = 0.42) nor the proportion of requests with subsequent hospital admissions (54.0% vs 49.0% p = 0.33). In the second period, there were differences in the proportion of patients with a previously diagnosed mental health disorder (95.3% vs 90.4% p = 0.049). There were significant differences in the distribution of the origin of requests. Being unemployed (OR:2.5 CI:1.2 - 5.2), not having completed high school (OR:2.01 CI:1.12 - 3.77) and having university education (OR:3.67 CI:1.27 - 10.57) degree were associated with hospital admission. Severe mental illness with criteria for mental health warrants may require more resources and different approaches due to a possible increase during and after the COVID-19 pandemic. Community based mental healthcare, incentivized follow-up by primary care and ambulatory treatment may be considered. Further research should evaluate both the national and international trends and associated factors.

Abstract 18473: Role of Linguistic Acculturation and Physical Activity With Risk of 1 Year Hospital Readmission After Suspected Acute Coronary Syndrome

Background: Disparities in acute coronary syndrome (ACS) outcomes after hospital care exist beyond racial and ethnic factors. In particular, low linguistic acculturation (LA) may impact care and lead to poorer prognosis. Few studies have examined LA’s impact on outcome disparities post-hospitalization and identified modifiable behaviors, such as physical activity (PA) engagement, that can mitigate risk. Aim: To evaluate the association of LA with 1-year hospital readmission risk among patients evaluated for ACS and examine PA as an effect modifier. Methods: Patients evaluated for ACS in the emergency unit (n=609, 47.8% female, 58.0% Hispanic, 63±12yrs) were studied. LA was classified into three levels (low, intermediate, high) based on patient’s self-reported native and preferred languages and English fluency. Continuous total PA was objectively assessed 30 days post-discharge via a GENEActiv accelerometer worn on the non-dominant wrist. One-year all-cause hospital readmissions were ascertained via hospital medical record searches. Cox regression models used high LA as referent group. Results: Over 1-year follow-up, 264 (44.0%) patients had a subsequent hospital admission. Low LA was associated with increased 1-year readmission risk after adjusting for demographic factors, comorbidities, disease severity, and PA indicators (intermediate HR=1.44; 95% CI: 0.91-2.28; low HR=1.63; 95% CI: 1.05-2.55; p-trend=0.035). PA moderated this association (p-interaction=0.003). Low LA was only associated with greater risk of 1-year readmission among those with low PA levels (below median of 158 min/day; HR=1.88; 95% CI: 1.00, 2.79). Among those with high PA, the association between low LA and risk of readmission was attenuated and not statistically significant (HR=1.46; 95% CI: 0.75, 2.83). Conclusion: Among a diverse cohort of patients with suspected ACS, LA was associated with reduced risk of 1-year hospital readmission. PA significantly moderated this relationship, with higher volumes of PA attenuating the positive association between low LA and increased risk of 1-year hospital readmission. These findings implicate low LA as a potential risk factor for readmission post-ACS and suggest increased engagement in PA can help mitigate this risk.

Natural Language Processing Identification of Symptoms in Emergency Department Visits in Patients Receiving Radiation

Patients undergoing radiotherapy (RT) for cancer often require emergency department (ED) attention with possible hospitalization. Designing strategies to mitigate hospital admissions requires understanding the causal symptoms to tailor interventional strategies. Natural language processing (NLP) has previously been shown to accurately identify documented symptoms and may help characterize factors contributing to admission. The objective of this study was to use NLP to identify documented symptoms during ED visits and their association with subsequent hospital admission of patients undergoing RT. A de-identified, single tertiary-care institution cohort of patients who received radiation between 2013 and 2022 was identified from the electronic health record using International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes. We applied a previously validated clinical Text Analysis and Knowledge Extraction System (cTAKES)-based NLP pipeline to extract Common Terminology Criteria for Adverse Events (CTCAE) encoded symptoms from ED encounter clinical notes. Chi-squared testing was used to compare demographics, and logistic regression was used to identify symptoms associated with subsequent admission from ED visits. We identified 14,007 patients who received radiation, of whom 270 (1.9%) experienced 302 ED visits during their radiation course. 141 (46.7%) of ED visits resulted in an admission. Among patients with an ED encounter, there were no differences in admission rates based on primary language (p = 0.771), sex (p = 0.824), marital status (p = 0.753), race (p = 0.222), or age (p = 0.123). In admitted patients, the top 5 symptoms were pain (94.3%), nausea (92.1%), vomiting (73.7%), constipation (70.9%), and weakness (63.8%). In patients who did not require admission, the most common symptoms were pain (84.5%), nausea (67.1%), vomiting (47.2%), headache (36.6%), and weakness (35.4%). The 10 symptoms most associated with admission from the ED based on logistic regression were malaise (OR 21.7, [95% CI 10.1 - 51.0]), lethargy (19.1, [8.5 - 51.3]), flushing (15.7, [8.6 - 30.4]), agitation (12.4, [3.5 - 78.7]), somnolence (10.3, [4.7 - 25.9]), fall (8.5, [3.7 - 23.2]), fatigue (7.8, [4.6 - 13.4]), constipation (6.9, [4.2 - 11.6]), nausea (5.8, [3.0 - 12.2]), and swelling (5.4, [3.3 - 9.1]). Admitted and non-admitted ED patients with cancer seen in the ED during radiotherapy are documented to experience similar symptoms, but certain symptoms are associated with a higher risk of hospital admission. NLP may offer a mechanism for early, automated identification to facilitate supportive interventions for patients at high risk for admission during radiotherapy.

Breastfeeding and impact on childhood hospital admissions: a nationwide birth cohort in South Korea

Benefits of breastfeeding for both the mother and the child are well established, but a comprehensive and robust study to investigate the protective effect of breastfeeding and attenuated time effect stratified by cause of morbidity are lacking. This study is based on the nationwide birth cohort in Korea that includes data on all infants born from 2009 to 2015. Of 1,608,540 children, the median follow-up period was 8.41 years (interquartile range, 6.76-10.06). When compared to children with fully formula feeding, the hospital admission rate was 12% lower in those with partially breastfeeding and 15% lower in those with exclusive breastfeeding. The apparent protective effect of breastfeeding was reduced with increasing age. Our study provides potential evidence of the beneficial association of breastfeeding on subsequent hospital admissions. The protective effect declined over time as the children grew older. Encouraging any breastfeeding for at least the first 6 months among infants is an important public health strategy to improve overall child health.

Hospital admission from the emergency department for selected emergent diagnoses during the first year of the COVID-19 pandemic in Ontario: a retrospective population-based study.

Avoidance of care during the pandemic may have contributed to delays in care, and as a result, worse patient outcomes. We evaluated markers of illness acuity on presentation to the emergency department among patients with non-COVID-19-related emergent diagnoses and associated outcomes. We conducted a retrospective study using linked administrative data from Ontario. We selected 4 emergent diagnoses, namely appendicitis, ectopic pregnancy, renal failure and diabetic ketoacidosis. We used the nonemergent diagnosis of cellulitis as a control. Our primary outcome of interest was hospital admission. Secondary outcomes were ambulance arrival, surgical intervention, subsequent hospital admission within 30 days of discharge from the emergency department or hospital and 30-day mortality. We compared outcomes during the first year of the COVID-19 pandemic (Mar. 15-Dec. 31, 2020) with a control period (Mar. 15-Dec. 31, 2018, and Mar. 15-Dec. 31, 2019). Emergency department visits for all conditions initially decreased during the pandemic. During this period, patients across all study diagnoses were more likely to arrive to the emergency department via ambulance. Patients with an ectopic pregnancy had higher odds of surgery in the pandemic period (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.04-1.55) but this was not observed among patients with appendicitis. Patients with renal failure had increased odds of hospital admission (OR 1.14, 95% CI 1.04-1.24) and 30-day mortality (OR 1.17, 95% CI 1.04-1.31) during the pandemic period. The pandemic period was associated with increased arrival to the emergency department via ambulance across all study diagnoses. Although patients with renal failure had increased hospital admission and death, and patients with ectopic pregnancy had an increased risk of surgery, there were no differences in outcomes for other populations, suggesting the health care system was able to care for these patients effectively.

Pregnancy and Emergency Department Utilization in North Carolina, 2016–2021: A Population-Based Surveillance Study

Pregnancy-associated complaints are a common reason for emergency department visits for women of reproductive age. Emergency department utilization during pregnancy is associated with worse birth outcomes for both mothers and infants. We used statewide North Carolina emergency department surveillance data between 2016 and 2021 to describe the sociodemographic factors associated with the use of emergency department for pregnancy-associated problems and subsequent hospital admission. North Carolina Disease Event Tracking and Epidemiologic Collection Tool is a syndromic surveillance system that includes all emergency department encounters at civilian acute-care facilities in North Carolina. We analyzed all emergency department visits between January 1, 2016 and December 31, 2021 for female patients aged 15-44 years residing in North Carolina with at least 1 ICD-10-CM code (analysis occurred in July 2021-October 2022). Each emergency department visit was categorized as pregnancy-associated if assigned ICD-10-CM code(s) indicated pregnancy. We stratified visits by age, race, ethnicity, county of residence, and insurance and compared them with estimated pregnant population proportions using 1-sample t-tests. We used multivariable logistic regression to determine whether pregnancy-associated visits were more likely to be associated with hospital admission and then to determine sociodemographic predictors of admission among pregnancy-associated emergency department visits. More than 6.4 million emergency department visits were included (N=6,471,197); 10.1% (n=655,476) were pregnancy-associated, significantly higher than the proportion of women estimated to be pregnant at any given time in North Carolina (4.6%, p<0.0001) and increased over time (8.6% in 2016 vs 11.1% in 2021, p<0.0001). Pregnancy-associated visits were lower than expected for ages 25-44 years and higher than expected for those aged 15-24 years, for those of Black race, and for patients residing in rural or suburban areas. The proportion admitted was higher for pregnancy-associated emergency department visits than for nonpregnancy associated (15.6% vs 7.0%, AOR=3.06 [95% CI=3.03, 3.09]). Pregnancy-associated emergency department visits for patients of Black race had 0.58 times (95% CI=0.57, 0.59) the odds of admission compared with White patients. Emergency department utilization during pregnancy is common. The proportion of pregnancy-associated emergency department visits among reproductive-age women is increasing, as are inpatient admissions from the emergency department for pregnancy-associated diagnoses. Use of public health surveillance databases such as the North Carolina Disease Event Tracking and Epidemiologic Collection Tool may help identify opportunities for improving disparities in maternal health care, especially related to access to care.

Corrigendum to: Factors associated with emergency department service outcomes for people with a mental health problem brought in by police: a retrospective cohort study.

Objective This study aimed to identify factors associated with an emergency department (ED) length of stay ≥4 hours (h) and hospital admission for people with a mental health problem brought in by police. Methods We undertook a retrospective, observational cohort study of state-wide adult ED mental health presentations brought in by police from 1 January 2012 to 31 December 2017. We used multivariable logistic regression to determine factors associated with an ED length of stay ≥4 h and hospital admission. Results In total, 9325 ED presentations with a mental health problem brought in by police to Queensland EDs were included. Factors most strongly associated with an ED length of stay ≥4 h included an Australasian Triage Score (ATS) of 1, an age of 85 years or older, night shift arrival and subsequent hospital admission. For hospital admission, an ATS of 1, an age of 85 years or older and an ED length of stay ≥4 h were the strongest factors. Conclusion Findings indicate opportunities for targeted mental health models of care to better support people brought in by police to an ED. Such models should involve ED, pre-hospital providers (police and ambulance) and mental health services to support early intervention and potentially reduce the likelihood of a long ED length of stay and subsequent hospital admission.

Effectiveness of long term therapy of inhaled Steroids in Childhood Asthma: A Systemic Review

Asthma exacerbations are a common and important cause of attendance at emergency departments and subsequent hospital admissions. This systemic review aimed to evaluate the effectiveness of long term therapy of inhaled steroids in childhood asthma. A search of PubMed (Medline) from January 1996 through February 2021 by using the keywords inhaled steroids in childhood asthma, identified potential studies. All randomized controlled trials and clinical trials of prophylactic inhaled steroid therapy for childhood asthma that included data on clinical outcomes (symptoms improvement and concomitant drug use) or laboratory outcomes (peak expiratory flow rate PEFR and (or) forced expiratory volume in first second FEV1) were included. Studies of children (?18?years old) with mild-to-moderate chronic or persistent asthma will be included.Results: In total, 15 of 116 studies met the inclusion criteria. Inhaled corticosteroids (ICS)versus placebo(3studies): ICS show good control on bronchial asthma by ratio(66.7%) and there was no improvement by placebo.ICS versus Mast cell stabilizer (DSCG, cromolyn sodium or nedocromil)(6 studies): by ICS there was better control of asthma, lower of airway hyperresponsivness, decrease risk for hospitalization in comparing to mast cell stabilizers by ratio of (66.7%).ICS versus LTRA (Montelukast)(3 studies) : by ICS better control of symptoms, modified exacerbation risk, improvement of pulmonary function in comparing to LTRA by ratio of (66.7%).ICS versus OCS (2 studies):more rapid clinical improvement results by OCS (50%), more improvement in the inflammatory markers by ICS(50%), reduction in rescue medication in both groups(100%).ICS alone (3 studies): good control of asthma including exercise asthma(66.7%).This Research concluded that the prophylactic inhaled steroids are more effective compared to placebo, mast cell stabilizer drugs and leukotriene receptor antagonist. ICS improving both clinical and laboratory outcomes in childhood asthma.&#x0D;

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases. To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED. This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023. The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated. A total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5-percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission. Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.

Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse.

Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury. Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity. A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27). Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

Non-randomized evaluation of hospitalization after a prescription for nirmatrelvir/ritonavir versus molnupiravir in high-risk COVID-19 outpatients.

To assess and compare subsequent hospital admissions within 30 days for patients after receiving a prescription for either oral nirmatrelvir/ritonavir or oral molnupiravir. We conducted a retrospective review of 3207 high-risk, non-hospitalized adult COVID-19 patients who received a prescription for molnupiravir (n = 209) or nirmatrelvir/ritonavir (n = 2998) at an academic medical centre in New York City from April to December 2022. Variables including age, vaccination status, high-risk conditions and demographic factors were pulled from the electronic medical record. We used multivariable logistic regression to adjust for potential confounding variables. All-cause 30 day hospitalization was not significantly different between patients who received nirmatrelvir/ritonavir compared with molnupiravir (1.4% versus 1.9%, P value = 0.55). The association between COVID-related hospitalization and medication was also not significant (0.7%versus 0.5%, P value = 0.99). Patients who received molnupiravir were more likely to have more underlying high-risk conditions. After adjusting for potential confounders, the odds of all-cause hospitalizations were not significantly different between patients who received nirmatrelvir/ritonavir compared with molnupiravir (OR = 1.16, 95% CI: 0.4-3.3, P value = 0.79). These data provide additional evidence to support molnupiravir as a suitable alternative when other COVID-19 antivirals cannot be given.

Evolving swabbing practices for COVID-19 in a New Zealand emergency department during the early stages of an emerging pandemic.

To review if tests for suspected COVID-19 were performed according to the Ministry of Health (MoH) case definitions, identify patterns associated with testing outside of the case definition, and discuss the potential impacts on hospital services. This was a retrospective audit of patients presenting to the Wellington Hospital ED between 24 March 2020 and 27 April 2020 who were swabbed for COVID-19 in ED. Swabs were audited against the March 15th and April 8th MoH COVID-19 case definitions. Five hundred and thirty-six COVID-19 swabs for 518 patients were taken during the study period. There was poor alignment of testing with the March 15th case definition, with only 11.6% of the 164 swabs taken during this period meeting the case definition. Of the 145 swabs that did not meet the case definition, the majority (n = 119, 82.1%) met symptom criteria only. Alignment of testing with the wider April 8th case definition was much higher with 88.2% meeting criteria. Factors associated with being swabbed despite not meeting the case definitions included fever >38°, a diagnosis of cancer, subsequent hospital admission, and for the March case definition only 'contact with a traveller'. There were associations found between testing outside of criteria and specific variables potentially perceived as high-risk. Poor alignment of testing with case definitions can impact hospital services through the (mis)use of limited laboratory testing capacity and implications for resource management. Improved communication and feedback between clinicians and policymakers may improve case definition implementation in a clinical setting.

The clinical presentation, etiology, and disease progression of children with post-infectious bronchiolitis obliterans in Cape Town, South Africa

Objectives: We describe the clinical spectrum, etiology, and progression of children with post-infectious bronchiolitis obliterans (PIBO) from a low- and middle-income setting for which there is limited literature. Materials and Methods: A cross-sectional, retrospective, and descriptive study between November 2019 and October 2020 of all PIBO patients aged 6 months to 15 years managed at pediatric pulmonology service in Cape Town, South Africa. Results: Fifty-one patients with PIBO were enrolled; 78% were males, median age of 60 months (IQR 33–107). Median age at disease presentation was 6 months (IQR 3–12), 80% presented with cough; 94% required hospital admission, 92% needed supplemental oxygen therapy and 75% needed ventilatory support. Reported cigarette smoke exposure was high (47%). Adenovirus infection was the most common etiology (64%). Chest radiographic findings included lung hyperinflation (43 [84.3%]) and bronchiectasis (23 [45%]). Twenty-seven patients had spirometry and showed mixed (41% [n = 8]) or obstructive (27% [n = 12]) pattern with mean (standard deviation) forced expiratory volume in 1s (FEV1) z-score −3.3 (± 1.4), forced vital capacity (FVC) z-scores −2.4 (± 1.6), and FEV1/FVC z-score −3.1 (± 2.4). Systemic corticosteroids were used during initial presentation in 47 patients (92%). Forty-four patients (86%) required two or more subsequent hospital admissions. Improvement of symptoms was reported in 82% of patients with a mean follow-up period of 5 years. Cough (43% [n = 22]) and wheeze (39% [n = 20)]) were the most common reported current symptoms. Conclusion: PIBO is a recognized cause of pediatric obstructive lung disease in South African settings, with adenovirus pneumonia being the most common preceding illness. Symptoms of airway obstruction persist over time, but improvement was observed with treatment including corticosteroids.

Adding Tools to Our Toolkit: How to Care for Children with Autism and Challenging Behaviors (P11-9.007)

<h3>Objective:</h3> To better equip medical staff to care for specific needs of children with autism spectrum disorder while hospitalized. <h3>Background:</h3> Children with autism typically thrive on routine. In March of 2020, the covid-19 pandemic ensured everyone’s routines would change, as the world shut down. We saw patients with previously tolerable behaviors become unmanageable, causing emergency room visits and subsequent hospital admissions. This placed a burden on staff at hospitals to care for patients with challenging behaviors. Care was further complicated by unfamiliar noises, faces, and scenery and patients’ behaviors were met with medical and physical restraints, rather than prevention, redirection, and de-escalation. <h3>Design/Methods:</h3> With a team of a pediatric psychologist, neurodevelopmental disability residents, and nurse educators, we designed a six-part training series to educate nurses and ancillary staff on how to better care for patients with autism, with the goal of increasing their ability to prevent, de-escalate, and redirect challenging behaviors. The training was built in a hospital-supported, virtual learning platform. Participating staff included nurses, APPs, PCAs, sitters, and other ancillary staff. Pre- and post questions were designed to assess changes in the attitude, comfort, and knowledge of those who completed the training. <h3>Results:</h3> There was a statistically significant increase on all items scored (including attitude, comfort, and knowledge questions) as a result of the educational intervention. <h3>Conclusions:</h3> Children with autism are often met with fear instead of empathy, as they are more likely to express challenging behaviors while hospitalized. Our training series educates staff on how to better meet the needs of children with autism and challenging behaviors. We have shown that self-reported attitude, comfort, and knowledge among trainees significantly increased following completion of training. Future implications include adapting training to other providers in the hospital, including residents and attendings, and designing additional follow-up training opportunities for staff. <b>Disclosure:</b> Dr. Massrey has nothing to disclose. Dr. Wells has nothing to disclose. Ms. Gibbs has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier. Mrs. Choate has nothing to disclose. Mrs. Nelson Hall has nothing to disclose. Dr. Klinepeter has nothing to disclose.