Tertiary Care Emergency Department Research Articles

Assessment of respiratory rate monitoring in the emergency department.

This study aimed to compare the different respiratory rate (RR) monitoring methods used in the emergency department (ED): manual documentation, telemetry, and capnography. This is a retrospective study using recorded patient monitoring data. The study population includes patients who presented to a tertiary care ED between January 2020 and December 2022. Inclusion and exclusion criteria were patients with simultaneous recorded RR data from all three methods and less than 10 min of recording, respectively. Linear regression and Bland-Altman analysis were performed between different methods. A total of 351 patient encounters met study criteria. Linear regression yielded an R-value of 0.06 (95% confidence interval [CI] 0.00-0.12) between manual documentation and telemetry, 0.07 (95% CI 0.01-0.13) between manual documentation and capnography, and 0.82 (95% CI 0.79-0.85) between telemetry and capnography. The Bland-Altman analysis yielded a bias of -0.8 (95% limits of agreement [LOA] -12.2 to 10.6) between manual documentation and telemetry, bias of -0.6 (95% LOA -13.5 to 12.3) between manual documentation and capnography, and bias of 0.2 (95% LOA -6.2 to 6.6) between telemetry and capnography. There is a poor correlation between manual documentation and both automated methods, while there is relatively good agreement between the automated methods. This finding highlights the need to further investigate the methodology used by the ED staff in monitoring and documenting RR and ways to improve its reliability given that many important clinical decisions are made based on these assessments.

Geriatric End-of-Life Screening Tool Prediction of 6-Month Mortality in Older Patients

Emergency department (ED) visits by older adults with life-limiting illnesses are a critical opportunity to establish patient care end-of-life preferences, but little is known about the optimal screening criteria for resource-constrained EDs. To externally validate the Geriatric End-of-Life Screening Tool (GEST) in an independent population and compare it with commonly used serious illness diagnostic criteria. This prognostic study assessed a cohort of patients aged 65 years and older who were treated in a tertiary care ED in Boston, Massachusetts, from 2017 to 2021. Patients arriving in cardiac arrest or who died within 1 day of ED arrival were excluded. Data analysis was performed from August 1, 2023, to March 27, 2024. GEST, a logistic regression algorithm that uses commonly available electronic health record (EHR) datapoints and was developed and validated across 9 EDs, was compared with serious illness diagnoses as documented in the EHR. Serious illnesses included stroke/transient ischemic attack, liver disease, cancer, lung disease, and age greater than 80 years, among others. The primary outcome was 6-month mortality following an ED encounter. Statistical analyses included area under the receiver operating characteristic curve, calibration analyses, Kaplan-Meier survival curves, and decision curves. This external validation included 82 371 ED encounters by 40 505 unique individuals (mean [SD] age, 76.8 [8.4] years; 54.3% women, 13.8% 6-month mortality rate). GEST had an external validation area under the receiver operating characteristic curve of 0.79 (95% CI, 0.78-0.79) that was stable across years and demographic subgroups. Of included encounters, 53.4% had a serious illness, with a sensitivity of 77.4% (95% CI, 76.6%-78.2%) and specificity of 50.5% (95% CI, 50.1%-50.8%). Varying GEST cutoffs from 5% to 30% increased specificity (5%: 49.1% [95% CI, 48.7%-49.5%]; 30%: 92.2% [95% CI, 92.0%-92.4%]) at the cost of sensitivity (5%: 89.3% [95% CI, 88.8-89.9]; 30%: 36.2% [95% CI, 35.3-37.1]). In a decision curve analysis, GEST outperformed serious illness criteria across all tested thresholds. When comparing patients referred to intervention by GEST with serious illness criteria, GEST reclassified 45.1% of patients with serious illness as having low risk of mortality with an observed mortality rate 8.1% and 2.6% of patients without serious illness as having high mortality risk with an observed mortality rate of 34.3% for a total reclassification rate of 25.3%. The findings of this study suggest that both serious illness criteria and GEST identified older ED patients at risk for 6-month mortality, but GEST offered more useful screening characteristics. Future trials of serious illness interventions for high mortality risk in older adults may consider transitioning from diagnosis code criteria to GEST, an automatable EHR-based algorithm.

Assessment of Pregnancy Desires for Patients With Pregnancy of Unknown Location Seen in the Emergency Department [ID 2683447

INTRODUCTION: Desire for pregnancy should be centered in all discussions surrounding pregnancy management, including management of pregnancy of unknown location (PUL). Little is known about the evaluation of pregnancy desires for patients presenting to the emergency department (ED) found to have PUL. METHODS: We performed a retrospective cohort study of patients presenting to a tertiary-care ED with a positive pregnancy test and previously unconfirmed intrauterine pregnancy in the first trimester between January 2020 and December 2022. We excluded patients with chief complaints regarding known intrauterine pregnancy. The primary outcome was documentation of pregnancy desire by the ED provider. The secondary outcome was assessment of pregnancy desiredness by consulting gynecologic providers. Chi-squared and Fisher exact tests assessed for demographic variables. Institutional review board approval was obtained. RESULTS: Four hundred ninety-seven patients were included. Overall, only 105 (21.1%) of all patients and 12 (13.5%) patients with PUL were asked about pregnancy desiredness by the ED provider. While not statistically significant, patients with PUL had the lowest rate of being asked their pregnancy desires, compared to patients with confirmed intrauterine pregnancy (22.7%), ongoing miscarriage (28.1%), or ectopic/adnexal pathology (20.0%) (P=.15). Of those asked, 11 patients (10.5%) reported the pregnancy was undesired and 7 (6.7%) were unsure. There were no significant associations between asking pregnancy desires and age, race, ethnicity, parity, insurance, and language. For patients added to the beta book and followed by gynecology, 59.3% of patients were asked about their pregnancy desires. CONCLUSION: This study highlights gaps in early pregnancy evaluation and counseling, with only one in five patients asked their pregnancy desires. Patients with adnexal pathology and PUL had among the lowest rates of counseling, compared to those with ongoing miscarriage. This research suggests a missed opportunity for comprehensive pregnancy options counseling and management in the ED and the potential for improvement of care for patients with undesired PUL.

Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department

BackgroundBariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. MethodsWe conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. ResultsWe included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). ConclusionThis is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

Appropriateness of antibiotic prescribing for urinary tract infection in the emergency department of a tertiary care hospital

BackgroundUrinary tract infections (UTIs) are frequently diagnosed in the Emergency Departments (EDs) in Saudi Arabia. Despite their prevalence, there is a lack of localized data on antibiotic prescribing practices for UTIs in EDs, hampering optimal patient care and antibiotic resistance management. ObjectiveThis study aimed to evaluate the appropriateness of antibiotic prescriptions for UTI patients by examining adherence to treatment guidelines at a tertiary care ED in Saudi Arabia. MethodsA retrospective cohort analysis was performed in UTI patients with ≥18 years of age who were presented to the ED at a tertiary care hospital between January 2022 and January 2023. 179 patients were randomly selected for enrollment, and data related to their demographics, medical history, microbial isolation, administered antibiotics, and incidence of recurrent infections were collected. ResultsCiprofloxacin (38 %), Cefuroxime (26.8 %), and Nitrofurantoin (16.8 %) were the most prescribed antibiotics. The female population accounted for 87.3 % of UTI cases. Notably, 40.7 % lacked microbial growth or data. Inappropriateness was found in 55.3 % of selection, 27.9 % of dosing, and 38.5 % of treatment duration confined to antibiotics in UTI management. Moreover, complicated UTIs rather than duration and indication for antibiotic therapy were independent risk factors for the re-occurrence of UTIs. ConclusionsThe study depicted an overall 44.7 % of appropriate antibiotic prescriptions in UTI patients. However, it also highlighted the necessity for tailored interventions and promotional efforts aimed at promoting the rational use of antibiotics in patients, thereby preventing resistance and treatment failure.

An emergency department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture

Abstract Falls and osteoporosis are risk factors for fragility fractures. Bone mineral density (BMD) assessment is associated with better preventative osteoporosis care, but it is underutilized by those at high fracture risk. We created a novel electronic medical record (EMR) alert-driven protocol to screen patients in the emergency department (ED) for fracture risk and tested its feasibility and effectiveness in generating and completing referrals for outpatient BMD testing after discharge. The EMR alert was configured in two tertiary-care EDs and triggered by the term “fall” in the chief complaint, age (≥65 years for women, ≥70 years for men), and high fall risk (Morse score ≥ 45). The alert electronically notified ED study staff of potentially eligible patients. Participants received osteoporosis screening education and had BMD testing ordered. From November 15, 2020 to December 4, 2021, there were 2608 EMR alerts among 2509 patients. We identified 558 patients at high-risk of fracture who were screened for BMD testing referral. Participants were excluded for: serious illness (N = 141), no documented health insurance to cover BMD testing (N = 97), prior BMD testing/recent osteoporosis care (N = 58), research assistant unavailable to enroll (N = 53), concomitant fracture (N = 43), bedridden status (N = 38), chief complaint of fall documented in error (N = 38), long-term care residence (N = 34), participation refusal (N = 32), or hospitalization (N = 3). Of the 16 participants who had BMD testing ordered, 7 scheduled and 5 completed BMD testing. EMR alerts can help identify subpopulations who may benefit from osteoporosis screening, but there are significant barriers to identifying eligible and willing patients for screening in the ED. In our study targeting an innovative venue for osteoporosis care delivery, only about 1% of patients at high-risk of fracture scheduled BMD testing after an ED visit. Adequate resources during and after an ED visit are needed to ensure that older adults participate in preventative osteoporosis care.

Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department.

Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL. This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics. We included 429 patients with a mean age of 67.7years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.

Impact of the COVID-19 Pandemic on Therapy and Outcome of Acute Exacerbations of Chronic Obstructive Lung Disease at the Emergency Department.

This study compared the treatment outcomes of acute exacerbation of COPD (AECOPD) at an academic tertiary care emergency department before and during the COVID-19 pandemic. Analyzing data from 976 patients, our study showed a significant surge in overall respiratory therapy interventions amidst the noticeable decline in the total number of AECOPD cases during the pandemic. The marked increase in the utilization of non-invasive ventilation (NIV) was particularly important, soaring from 12% to 18% during the pandemic. Interestingly, this heightened reliance on NIV stood in contrast to the stability observed in other therapeutic modalities, including oxygen insufflation alone, high-flow nasal cannulas, and invasive ventilation. This distinctive treatment pattern underscores the adaptability of healthcare providers in the face of novel challenges, with a discernible emphasis on the strategic utilization of NIV. The shift in patient acuity during the pandemic became evident as the data showed a cohort of individuals presenting with AECOPD who were more severely ill. This was reflected in the increased use of NIV and, notably, a statistically significant rise in one-year mortality rates-from 32% before the pandemic to 38% during the pandemic (p = 0.046). These findings underscore the intricate balance healthcare providers must strike in navigating the complexities of patient care during a public health crisis. A closer examination of the longitudinal trajectory revealed a subtle decrease in re-admission rates from 65% to 60%. The increased reliance on NIV, a key finding of this investigation, reflects a strategic response to the unique demands of the pandemic, potentially influenced by both medical considerations and non-medical factors, such as the prevalent "fear of aerosols" and the imperative to navigate transmission risks within the healthcare setting. These insights contribute to understanding the evolving dynamics of AECOPD management during public health crises.

Unplanned revisits of older patients to the emergency department

IntroductionOlder patients currently represent up to 12%−24% of all emergency department (ED) visits. While increasing in number, they are also at high risk of revisits once discharged. The rate of ED revisits within 72 h is a key indicator of the quality of care in emergency medicine and varies between 1% and 15%. The reasons for ED revisits are natural course of illness, misdiagnosis, lack of homecare, and self-discharge against medical advice. However, the risk factors for ED revisits have not been fully investigated. Therefore, this study aimed to analyze the incidence of ED revisits and identify the risk factors for ED revisits within 72 h after ED discharge.MethodsIn this retrospective study, older patients (≥70 years) were consecutively enrolled if they presented with an Emergency Severity Index of 2 or 3 in a tertiary care ED in 2019, with discharge after the ED visit. The primary endpoint was the frequency of unplanned ED revisits within 72 h after ED discharge. The secondary endpoints were the reasons and potential risk factors for ED revisits. Univariate and multivariate logistic regression models were used.ResultsA total of 592 older patients were enrolled, of whom 30 (5.1%) revisited the ED within 72 h. Gastrointestinal diagnosis [odds ratio (OR), 2.9; 95% confidence interval [CI], 1.04–8.2; p = 0.043) and nausea in particular (OR, 3.5; 95% CI, 1.3–9.4; p = 0.016) were significant risk factors for ED revisits. Furthermore, discharge against medical advice (OR, 5.6; 95% CI, 1.7–18.1; p = 0.004) and ED presentation during the night (OR, 2.7; 95% CI, 1.2–6.1; p = 0.014) were significant risk factors for ED revisits within 72 h after discharge, respectively.ConclusionAlthough the frequency of ED revisits among older patients at 72 h after discharge tends to be low and most revisits were illness-related, all older patients need to be assessed for risk factors for ED revisits. Discharge should be carefully evaluated to improve patient safety and provide the best healthcare to this frail population.

Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription.

Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial.

Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients. This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model. Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001). Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.

Evaluating the Reliability of a Remote Acuity Prediction Tool in a Canadian Academic Emergency Department

There is increasing interest in harnessing artificial intelligence to virtually triage patients seeking care. The objective was to examine the reliability of a virtual machine learning algorithm to remotely predict acuity scores for patients seeking emergency department (ED) care by applying the algorithm to retrospective ED data. This was a retrospective review of adult patients conducted at an academic tertiary care ED (annual census 65,000) from January 2021 to August 2022. Data including ED visit date and time, patient age, sex, reason for visit, presenting complaint and patient-reported pain score were used by the machine learning algorithm to predict acuity scores. The algorithm was designed to up-triage high-risk complaints to promote safety for remote use. The predicted scores were then compared to nurse-led triage scores previously derived in real time using the electronic Canadian Triage and Acuity Scale (eCTAS), an electronic triage decision-support tool used in the ED. Interrater reliability was estimated using kappa statistics with 95% confidence intervals (CIs). In total, 21,469 unique ED patient encounters were included. Exact modal agreement was achieved for 10,396 (48.4%) patient encounters. Interrater reliability ranged from poor to fair, as estimated using unweighted kappa (0.18, 95% CI 0.17 to 0.19), linear-weighted kappa (0.25, 95% CI 0.24 to 0.26), and quadratic-weighted kappa (0.36, 95% CI 0.35 to 0.37) statistics. Using the nurse-led eCTAS score as the reference, the machine learning algorithm overtriaged 9,897 (46.1%) and undertriaged 1,176 (5.5%) cases. Some of the presenting complaints under-triaged were conditions generally requiring further probing to delineate their nature, including abnormal lab/imaging results, visual disturbance, and fever. This machine learning algorithm needs further refinement before being safely implemented for patient use.

Treatment, Management, and Otolaryngology Consultation for Epistaxis in the Emergency Room: An Institutional Experience.

Epistaxis is a common reason for emergency department (ED) visits, accounting for approximately 1 of every 200 ED visits in the United States annually and up to one-third of all otolaryngology (ENT)-related ED encounters. To detail reasons for ENT consultation for epistaxis in the ED, understand how consultation impacts patient care, assess follow-up patterns after emergency care, and study patient care after transfer or referral into the ED. Retrospective chart review of 592 adult patients with epistaxis managed in a tertiary care ED setting between 2017 and 2018. Patients with known follow-up, ENT consult in the ED, or admission were included, while patients with trauma, recent head and neck surgery, or abnormal anatomy were excluded. The most common reasons for ENT consultation for epistaxis were for advanced management, referral to the ED from an outside facility or provider, and recent head and neck surgery. In total, 48.2% of patients treated for epistaxis in the ED received an ENT consultation. ENT consultation was associated with a higher likelihood of receiving absorbable or nonabsorbable packing (92.4% vs 36.1%). In total, 40.4% of patients referred into the ED from an outside facility or provider had no change in their management after receiving an ENT consult. Patients referred to the ED and White patients were significantly more likely to receive an ENT consult. Secondary analyses revealed that more White patients had an established outpatient ENT provider than patients of other races. On multivariate analysis, patients who received an ENT consult spent 75.2 min longer in the ED. The high percentage of patients referred or transferred to the ED for epistaxis management with no change in interventions after ENT consultation indicates a continued need to develop more precise clinical care pathways. Additionally, there may be gaps between White and non-White patients in access to ENT care.

Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations

Objective To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED). Study design Prospective study of children 2–18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7–10 days after discharge. Results 564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes. Conclusions Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Epidemiology and clinical characteristics of adult patients presenting to a low resource, tertiary care emergency department in Pakistan: Challenges & Outcomes.

Emergency Departments (EDs) play a major role in managing acute and chronic illnesses, especially in low-to-middle-income countries like Pakistan, which lacks effective primary healthcare. This study reports the epidemiology and clinical characteristics of patients presenting over a two-year period at the Indus Hospital and Health Network (IHHN) adult ED in Karachi, Pakistan. This is a retrospective observational study conducted through chart review of 264,859 patients, aged 16 years and above, who presented to the IHHN ED, Korangi Campus, from January 2019 to December 2020 after obtaining approval from IHHN IRB. Men were found to be the predominant presenting gender, with a slight rise in the number of women in 2020. The most frequent age group in 2019 was 15-25 (27.7%), whereas it was 25-35 years in 2020 (24.1%), with a decline in total number of elderly visits seen in comparison to previous years. The most frequently seen disposition was 'referral to clinic' in 2019 (48.4%) and 'discharged' in 2020 (39%). Out of all dispositions, maximum Length of stay (LOS) was seen in patients who left against medical advice in both years. Patient acuity showed the highest number of P3 (moderately ill) patients in both years. Infectious diseases accounted for greater than 10% of patients in both years (17.2% and16.5%), followed by gastrointestinal complaints (15.7% and 11.3%), genitourinary complaints (14.9% and 7.9%), and trauma (11.9% and 12.4%). Knowledge of epidemiology and clinical characteristics of patients can help facilitate timely planning of staff deployment and allocation of resources to avoid overcrowding, improve patient outcomes, and increase patient satisfaction through timely management.

Comparison of the diagnostic utility of CHOKAI, STONE and STONE PLUS scores in predicting ureteral stones larger than 5 mm

Objective: The objective of this study is to assess the diagnostic accuracy of CHOKAI, STONE, and STONE plus scores in detecting ureteral stones larger than 5 mm. Methods: This comparative diagnostic accuracy study was performed in a tertiary care emergency department (ED) and included consecutive patients who presented to the ED with flank pain over a 1-year period. The performance of these scoring scales in detecting ureteral stones measuring &gt;5 mm was determined by area under the receiver operating characteristics (AUROC) comparison. Results: Ureteral stones were detected in 270 (70.3%) of 384 patients included in the study. While 146 patients (54.1%) had ureteral stones measuring &lt;5 mm, 124 patients (54.1%) had stones measuring 5 mm or more in size. The performance of the CHOKAI score in predicting ureteral stones was superior to that of the STONE PLUS score; STONE PLUS score was also superior to STONE score ( p &lt; 0.001). Analysis of the diagnostic value of CHOKAI score and STONE PLUS scores in predicting &gt;5-mm stones showed no statistically significant difference ( p = 0.59). Conclusion: CHOKAI and STONE PLUS scores are useful in predicting &gt;5-mm ureteral stones and have similar diagnostic utility to each other. STONE score does not provide accurate diagnostic information about ureteral stones larger than 5 mm. Level of evidence: Level 2b

91. Implementation of a blood culture algorithm in emergency department patients as a diagnostic stewardship intervention

Abstract Background Blood cultures (BCx) are commonly ordered for patients at low risk of bacteremia. Liberal ordering can increase false-positive results due to contamination, along with increasing length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented an algorithm for appropriate blood culture obtainment (Figure 1) in an academic tertiary care emergency department (ED) and assessed the intervention’s impact on various operational, clinical, and safety metrics.Figure 1:ED Blood culture algorithm Methods We performed a prospective cohort study in the Duke University Hospital ED from 12/2022 to 3/2023 using historical controls from 12/2020-11/2022. The BCx algorithm was disseminated in-person, electronically, and accessible online. Weekly chart review of all eligible patients for algorithm adherence was completed by 7 ED clinicians with monthly feedback provided to all ED providers. We defined a BCx event as 1 or more BCx sets within 24 hours. We excluded patients &amp;lt; 18 years, absolute neutrophil count &amp;lt; 500 109/L, and heart and lung transplant recipients. We measured BCx order volume, indication, algorithm adherence, BCx positivity rate, antibiotic days of therapy (DOT), and 30-day hospital readmission. Results Average monthly BCx volume was 1387 pre-intervention compared to 1226 post-intervention (p= 0.046). An increase in culture positivity was see post-intervention with a rate of 13.9% compared to 11.23% in the pre-intervention group (Figure 2, p&amp;lt; 0.001). The majority of the 2168 BCx adhered to the algorithm. (Figure 3). The most common reasons for non-adherence were isolated fever or leukocytosis (29%), non-severe community-acquired pneumonia or healthcare-associated pneumonia (6.9%) and non-severe cellulitis (4%). No change in DOT (786 vs. 783 days of therapy per 1000 patient days, p-value 0.85) (Figure 4) or monthly 30-day hospital readmission (21.1% vs 19.6%, p-value 0.30) was observed.Figure 2:Blood cultures drawn per month and % appropriate pre/post-intervention (N=2168)Figure 3:Algorithm Adherent vs. Algorithm Non-Adherent blood cultures per month (N=2168)Figure 4:Emergency Department anti-bacterial days of antibiotic therapy per 1000 patient days Conclusion Introduction of a BCx algorithm in an academic tertiary care ED, resulted in a decrease in BCx volume, increase in BCx positivity rate, and no increase in DOT or readmission was observed. (Table 1)Table 1:Blood culture volume, positivity rate, days of antibiotic therapy, and 30-day readmission Disclosures Jessica Seidelman, MD, MPH, Uptodate: content editor for pelvic osteomyelitis page

Survey of Vaccine Hesitancy in Patients Visiting Three Tertiary-care Emergency Departments in Southeast Louisiana.

Vaccine hesitancy has been a barrier to achieving herd immunity during the coronavirus 2019 (COVID-19) pandemic. Having low socioeconomic status and education levels, and being a person of color, are associated with higher COVID-19 infection risk and worse outcomes. These same groups are associated with higher vaccine hesitancy. The state of Louisiana has one of the lowest vaccination rates in the country. In this study we aimed to identify demographic, perspective, and health behavior factors associated with vaccine hesitancy in emergency departments (ED) in Southeast Louisiana. A cross-sectional survey was distributed at three tertiary-care hospital EDs. Patients >18years old and not in acute distress were recruited between April-July 2021. The 37-item questionnaire addressed socioeconomic demographics, social determinants of health, COVID-19 safety practices, thoughts and perceptions on COVID-19 and vaccines, sources of COVID-19 and vaccine information, and trust in the healthcare system. Overall, 247 patients completed our survey. Of those, 29.6% reported they were vaccine hesitant. These respondents were significantly more likely, when compared to vaccine-acceptant respondents, to never have married, to have some college education, make less than <$25,000 in household earnings yearly, be unsure whether vaccines prevent disease, not have discussed the COVID-19 vaccine with their primary care doctor, and to prefer to do their own research for COVID-19 vaccine information. We observed no statistically significant differences based on gender, race/ethnicity, parental status, area of living, or their perceived risk of needing hospitalization for treatment or dying from the virus. Vaccine hesitancy was associated with multiple socioeconomic factors, perspectives, and beliefs. Vaccine-hesitant individuals were more uncertain about the safety of the COVID-19 vaccine, the feasibility of obtaining the vaccine, and its efficacy. Public health interventions aimed at these findings and improving public trust in healthcare systems are needed to increase vaccine acceptance.

Sustainable Purchasing Practices: A Comparison of Single-use and Reusable Pulse Oximeters in the Emergency Department.

Delivering healthcare requires significant resources and creates waste that pollutes the environment, contributes to the climate crisis, and harms human health. Prior studies have generally shown durable, reusable medical devices to be environmentally superior to disposables, but this has not been investigated for pulse oximetry probes. Our goal was to compare the daily carbon footprint of single-use and reusable pulse oximeters in the emergency department (ED). Using a Life Cycle Assessment (LCA), we analyzed greenhouse gas (GHG) emissions from pulse oximeter use in an urban, tertiary care ED, that sees approximately 150 patients per day. Low (387 uses), moderate (474 uses), and high use (561 uses), as well as cleaning scenarios, were modelled for the reusable oximeters and compared to the daily use of single-use oximeters (150 uses). We calculated GHG emissions, measured in kilograms of carbon dioxide equivalents (kgCO2e), across all life cycle stages using life-cycle assessment software and the ecoinvent database. We also carried out an uncertainty analysis using Monte Carlo methodology and calculated the break-even point for reusable oximeters. Per day of use, reusable oximeters produced fewer greenhouse gases in low-, moderate-, and high-use scenarios compared to disposable oximeters: 3.9kgCO2e, 4.9kgCO2e, 5.7kgCO2e vs 23.4kgCO2e, respectively). An uncertainty analysis showed there was no overlap in emissions, and a sensitivity analysis found reusable oximeters only need to be used 2.3 times before they match the emissions created by a single disposable oximeter. Use phases associated with the greatest emissions varied between oximeters, with the cleaning phase of reusables responsible for the majority of its GHG emissions (99%) compared to the production phases of the single-use oximeter (74%). Reusable pulse oximeters generated fewer greenhouse gas emissions per day of use than their disposable counterparts. Given that the pulse oximeter is an ubiquitous piece of medical equipment used in emergency care globally, carbon emissions could be significantly reduced if EDs used reusable rather than single-use, disposable oximeters.

Emergency department use of an electronic differential diagnosis generator in the evaluation of critically ill patients.

Accurate diagnosis is an essential component of managing critically ill emergency department (ED) patients. Electronic diagnosis generators (EDGs) are software tools which assist clinicians in their diagnosis generation; however, they have not been evaluated for use for critical ED patients. We aimed to evaluate the use of an EDG for this population to determine its impact on diagnosis generation and diagnostic testing. We performed an observational study on usage of an EDG in the high-acuity area of a tertiary care ED. The EDG was used by residents evaluating each patient in the area. The resident used the EDG when the case was felt to have diagnostic uncertainty and completed a data collection tool. Data were summarized by frequencies. Chi-squared or Fisher's exact tests were used to assess the association of added value of the EDG for diagnosis generation and diagnostic testing. Over the 8-month study period, the EDG was utilized to evaluate 98 critical ED patients, of whom 60% were female, 7% were pediatric, and 46% were elderly. It was used most commonly for gastroenterological, infectious disease/immunologic, metabolic/renal, and neuropsychiatric presentations, and was least used for trauma presentations. Use of the EDG led to a diagnosis not initially considered in 47% of cases and led to additional diagnostic testing in 4% of cases. EDGs have some potential to improve diagnosis in critical EM patients by expanding the differential diagnosis and, to a lesser extent, altering diagnostic testing.