Emergency Department Of Tertiary Care Hospital Research Articles

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.

What adult patients prefer for reporting their pain levels, and frequency of reassessment when in the emergency department

ObjectivesThis study interviewed adult patients presenting to the emergency department (ED) for various pain conditions enquiring about their preferred tool for reporting pain severity and preferred time interval between initial assessment and subsequent pain reassessments. MethodsA prospective observational (cross-sectional) study was conducted in adult patients with acute pain in a tertiary care hospital ED setting. Patients' initial pain score was recorded using NRS (numerical rating scale) pain scale, and appropriate analgesia offered. Once the patient had been evaluated by an attending physician, a research team member interviewed the patient regarding the pain reassessment time and preferred pain assessment tool. The pain assessment tools evaluated in this study were NRS, PS (picture scale or face pain scale), VRS (verbal rating scale), and VAS (visual analogue scale). The patients were presented with the four pain assessment tools (in their primary language) through an audio-visual on an electronic tablet display. Results200 (138 male, mean age 36.5 ± 11.17) patients participated in the study. With increasing age, pain reassessment interval increased by 0.19 min (95% CI 0.03–0.36 min). Males requested pain reassessment 6.7 min (95% CI 2.2–10.8) faster than females. In this study, the preferred interval for pain reassessment was reported as a mean of 22.8 (SD + −13.6) minutes. There was no relationship reported between time reassessment and pain severity (P = 0.22). Out of 200 subjects, irrespective of the initial pain scores, 100 preferred NRS. NRS was preferred by patients with mild to moderated pain due to the perception of being faster. However, patients with severe pain choose a non-NRS scale to prioritize accuracy. ConclusionThere was no influence found between the initial pain severity scores and the desired frequency of pain reassessment. However, associations were identified between the time for pain reassessment interval and age, sex, and geographical region. Patients with severe pain preferred PS or VRS while patients with mild/moderate pain preferred the NRS.

Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study.

Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.

Modeling the value of an emergency department influenza vaccination program

BackgroundSeasonal influenza continues to present a significant annual burden as the vaccination rate in the United States is 51.8%. Emergency Department (ED) based influenza programs have been successfully implemented and improve vaccine uptake, reduce incidence and costs, and improve outcomes. ObjectiveTo develop a predictive model to assess preventable influenza cases, hospitalizations, fatalities, and incremental cost avoidance based on the unvaccinated population. MethodsA retrospective cohort of ED encounters limited to Medicare and Medicaid populations was performed across 14 tertiary care hospital EDs and six freestanding EDs for 2020. The total number of unvaccinated individuals was identified to determine the potential impact of an ED vaccination campaign. The average cost and loss per inpatient stay was identified from prior industry Medicare benchmark data and was utilized to extrapolate Medicaid losses. Results from published cost-effectiveness studies identified the vaccination thresholds to prevent one additional case of influenza, one additional hospitalization, and one additional fatality. ResultsA total of 39,463 unvaccinated individuals were identified, with 14,064 classified as Medicare, and 25,379 classified as Medicaid. Assuming a 95% target outreach, 90% medical eligibility, and 70% acceptance rate, 414 influenza cases would be prevented (266 Medicaid, 148 Medicare), 28 hospitalizations would be prevented (18 Medicaid, 10 Medicare), and eight deaths would be prevented (5 Medicaid, 3 Medicare). Accordingly, a reduction in admissions would prevent $409,360 in total inpatient medical costs and $36,232 in losses to healthcare systems. ConclusionAn ED-based influenza vaccination program would have a measurable impact on patient influenza disease burden and associated medical expenditures.

Web-Based Knowledge Translation Tool About Pediatric Acute Gastroenteritis for Parents: Pilot Randomized Controlled Trial.

Acute gastroenteritis (AGE) in children is a leading cause of emergency department (ED) visits, resulting in substantial health care costs and stress for families and caregivers. The majority of pediatric AGE cases are caused by viral infections and can be managed at home using strategies to prevent dehydration. To increase knowledge of, and support health decision-making for, pediatric AGE, we developed a knowledge translation (KT) tool (fully automated web-based whiteboard animation video). The aim of this study was to assess the potential effectiveness of the web-based KT tool in terms of knowledge, health care decision-making, use of resources, and perceived benefit and value. A convenience sample of parents was recruited between December 18, 2020, and August 10, 2021. Parents were recruited in the ED of a pediatric tertiary care hospital and followed for up to 14 days after the ED visit. The eligibility criteria included parent or legal guardian of a child aged <16 years presenting to the ED with an acute episode of diarrhea or vomiting, ability to communicate in English, and agreeable to follow-up via email. Parents were randomized to receive the web-based KT tool (intervention) about AGE or a sham video (control) during their ED visit. The primary outcome was knowledge assessed before the intervention (baseline), immediately after the intervention, and at follow-up 4 to 14 days after ED discharge. Other outcomes included decision regret, health care use, and KT tool usability and satisfaction. The intervention group participants were invited to participate in a semistructured interview to gather additional feedback about the KT tool. A total of 103 parents (intervention: n=51, 49.5%, and control: n=52, 50.5%) completed the baseline and postintervention assessments. Of these 103 parents, 78 (75.7%; intervention: n=36, 46%, and control: n=42, 54%) completed the follow-up questionnaire. Knowledge scores after the intervention (mean 8.5, SD 2.6 vs mean 6.3, SD 1.7; P<.001) and at follow-up (mean 9.1, SD 2.7 vs mean 6.8, SD 1.6; P<.001) were significantly higher in the intervention group. After the intervention, parents in the intervention group reported greater confidence in knowledge than those in the control group. No significant difference in decision regret was found at any time point. Parents rated the KT tool higher than the sham video across 5 items assessing usability and satisfaction. The web-based KT tool improved parental knowledge about AGE and confidence in their knowledge, which are important precursors to behavior change. Further research is needed into understanding what information and delivery format as well as other factors influence parents' decision-making regarding their child's health. ClinicalTrials.gov NCT03234777; https://clinicaltrials.gov/ct2/show/NCT03234777. RR2-10.1186/s40814-018-0318-0.

A cross-sectional study on bacterial contamination on the touchscreens and posterior surfaces of smartphones of emergency department staff.

Cleaning smartphones of healthcare workers (HCWs) is generally recommended; however, most previous studies on bacterial contamination of smartphones assessed touchscreens alone. This study compared the prevalence of bacterial contamination on touchscreens and posterior surfaces of smartphones owned by HCWs. A cross-sectional study of smartphones used by HCWs working at an emergency department (ED) at a Japanese tertiary care hospital was conducted. Bacteria on each surface of the smartphones were isolated separately. Descriptive statistics were used to describe the prevalence of microbial contamination on each surface of the smartphones and the types of associated bacterial species. Fisher's exact test was used to compare dichotomous outcomes. The smartphones of 40 HCWs working in the ED of a Japanese tertiary care hospital were examined. The touchscreens and posterior surfaces were contaminated in 26 (65.0%) and 36 (90.0%) smartphones, respectively, indicating the posterior surface was more frequently contaminated (p = 0.014). Bacillus species and coagulase-negative staphylococci were most frequently isolated from each surface of the smartphones. The posterior surface of a smartphone was more significantly contaminated with bacteria than the touchscreen. Both surfaces of smartphones need to be cleaned to prevent bacterial contamination in healthcare environments.

Pediatric Injury Patterns Presenting at a Tertiary Care Hospital Emergency Department

Introduction: Injuries in the pediatric population relate to significant liability, especially in low- and middle-income countries.1 The aim of this study is to decipher the patterns of pediatric injury in Pakistan. This may give the data on the pattern of pediatric injuries, thereby strategies could be made to deal such patients and eventually reduce the mortalities and morbidities. Objective: To evaluate pediatric injury patterns presenting in emergency department of Liaquat National Hospital, Karachi. Methodology: The study was held at the Emergency department of LNH for six months from 11th may 2018 to 11th November 2018. It was a cross sectional study. Ninety children suffering from trauma as per their history were included in this study. Demographics were noted of all the patients enrolled in the study. An approved Performa was used for recording the outcome variables . Results: - The median age of the children was 4.81±3.12 years. Out of 90 children, 71(79%) were boys and 19(21%) were girls. Pattern of injury were included road traffic injuries (54.4%),falls from height (31.1%), poisoning (9%) ,burns (3.3%) and electrocution (2.2%) Conclusion: We conclude that the patterns of pediatric injuries in children presenting in accident and emergency department shows road traffic accidents as the leading cause followed by fall from height, poisoning and burns. The study emphasizes the need to build an injury surveillance in the emergency dept that would be a building block for a national injury surveillance database. Along with it, study highlights necessary injury prevention measures that would assist in addressing preventable childhood injuries in Pakistan . Keywords: Pediatric injuries, Road traffic injuries, Poisoning

COVID-19 pandemic: impact of lockdown measures on presentations to a Singapore tertiary care hospital emergency department.

COVID-19 pandemic: impact of lockdown measures on presentations to a Singapore tertiary care hospital emergency department.

An evaluation of violence prevention education in healthcare

BackgroundAn issue of international concern, violence towards healthcare workers from patients and visitors negatively affects the safety and health of workers and the quality of care they deliver. The principal intervention to address violence has been violence prevention (VP) educational programs for healthcare workers. Evaluating the overall effectiveness of VP education has been difficult due to pervasive underreporting of incidents, the complexity of healthcare settings, and the varying reasons for violence. MethodsA theory-driven, realist evaluation was conducted to examine the conditions under which VP education is effectively learned and applied in emergency department (ED) settings. Nine research sites included three rural, three community and three urban, tertiary care hospital EDs. Data from individual and focus group interviews with 136 participants was used to test a program theory (PT) of why and how VP education works, for whom, under what circumstances. ResultsThe initial program theory of VP education was based on a realist literature review and input from content experts. Qualitative data from the evaluation refined the initial program theory, yielding 15 explanations for how and why educational and workplace contexts influence ED workers' learning and application of VP knowledge and skills—ultimately reducing the risk of violence. While the explanations result from individual worker’s perspectives of VP education, they are situated in a broader context of organizational safety climate including organizational leaders’ response to employees’ experiences with violence and feelings of physical and psychosocial safety. ConclusionsThis research provides practical evidence for healthcare stakeholders to inform education, policy and practice decisions to increase the VP education effectiveness.

49 Implementation of a Sensory Toolkit in the Emergency Department for Children with Autism Spectrum Disorder

Abstract Background Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by deficits in social communication and restricted, repetitive patterns of behaviour, interests, or activities. Children with ASD frequently visit the emergency department (ED), and present more for primary care-related issues and other non-emergent reasons than children without ASD. Visiting the ED can be challenging and stressful for children with ASD, their caregivers, and the healthcare professionals caring for them. Sensory Toolkits are a collection of sensory items that can help to distract and calm children, including during times of stress. We hypothesized that a Sensory Toolkit will improve the experience of children with ASD and their families in our ED. Objectives The primary objective of this study was to evaluate the effect of a Sensory Toolkit on the experience of children with ASD and their families visiting a tertiary-care hospital ED. Design/Methods After ethical approval was obtained, a pre-implementation survey was conducted on parents of children with ASD about prior experiences in the ED and their interest in a Sensory Toolkit. A Sensory Toolkit specific to children with ASD was developed through literature review and in consultation with families of children with ASD. The Sensory Toolkit, which included a light wand, squeeze ball, push-pop bubble toy, and other items, was launched in a tertiary-care hospital ED in June 2021 with 50 Toolkits. A post-implementation survey was conducted to explore parents’ experiences of their child using the Sensory Toolkit in the ED and to obtain feedback to help improve the Toolkit. Results In the pre-implementation survey, 80% (32/40) of parents felt that a Sensory Toolkit would improve the experience of children with ASD in the ED. Post-implementation, 100% (12/12; response rate ~25% from 50 Toolkits) of parents felt that the Sensory Toolkit was helpful for their child. Parents reported that the Sensory Toolkit was “AMAZING” and “A really great idea, thank you!”. Feedback provided regarding improvements that could be made to the Sensory Toolkit was highly patient-specific and often contradictory. One parent suggested more items to chew on while another parent suggested elimination of the chewable items and one parent loved the light up toy while another suggested to remove it. Conclusion The Sensory Toolkit contributes positively to the experience of children with ASD and their families in a tertiary-care hospital ED. This study will help inform improvement of the Sensory Toolkit in the ED, including consideration of more specialized Sensory Toolkits to meet individual patient needs. Given the success in the ED, the Sensory Toolkit could be expanded into other areas of the tertiary-care hospital and beyond.

Cocaethylene cardiotoxicity in emergency department patients with acute drug overdose.

Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co-ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p= 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p= 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p= 0.038). When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury.

P22-10 Prevalence and outcome of Covid-19 in patients with substance abuse disorder presented to tertiary care hospital emergency department

P22-10 Prevalence and outcome of Covid-19 in patients with substance abuse disorder presented to tertiary care hospital emergency department

Comparison of the NIO and EZIO for Resuscitative Vascular Access in the Emergency Department: A Quasi-Experimental, Before-and-After Study.

Intraosseous (IO) needle insertion is a key adjunctive procedure in the care of critically ill and injured patients in a variety of settings, including the battlefield. The NIO is a new, fully disposable, single-piece, IO device with potential practical advantages under austere conditions. We sought to compare the efficacy and safety of the NIO to an established, well-studied device, the EZIO, when used for resuscitative vascular access in the emergency department (ED). Retrospective, single-center, quasi-experimental, before-and-after, observational cohort study performed at an urban, tertiary-care hospital ED among adult patients receiving IO access during resuscitation. The before/NIO period lasted from July 1, 2019, to May 31, 2020, and the EZIO/after period from June 1, 2020, to April 30, 2021. Patient demographics, prehospital treatment, ED presentation, characteristics and results of IO insertion(s), potential procedure-associated adverse events, and ED and hospital outcomes were abstracted from the medical record. The primary outcome, rate of first-pass success (FPS), was compared between the NIO and EZIO periods using multivariable regression after adjustment for potential confounding factors. We enrolled 63 total patients/66 limbs (mean age 61 ± 18, 51% female), 34 patients/35 limbs during the NIO period and 29 patients/31 limbs during the EZIO period. The most common reason for IO insertion was cardiac arrest (40/63, 63%), followed by respiratory failure, trauma, and sepsis. The majority of IO insertions were performed at the proximal tibia (58/66, 88%) by senior emergency medicine residents or faculty. The overall rate of FPS was 53/66 (80%), 24/35 (69%) with the NIO compared to 29/31 (94%) with the EZIO. After multivariable modeling, the odds of FPS with the NIO vs. the EZIO was 0.19 (95% CI, 0.01-1.5, P = .16). Procedure-related adverse events were infrequent in both groups. In-hospital mortality was 45/63 (71%). We found that the NIO device was associated with a lower-than-expected rate of FPS compared to the EZIO device, although not significantly different after adjusting for between-group imbalances and considering limitations in the study design. Further, prospective research into the efficacy and safety of the NIO is needed before clinical use can be encouraged.

Impact of COVID-19 on Pediatric Mental and Behavioral Health Visits to the Emergency Department.

ObjectivesThis study aimed to describe changes in pediatric emergency department (ED) mental and behavioral health (MBH) visits before and during the early COVID-19 pandemic.MethodsWe retrospectively reviewed medical records of patients aged from 5 to 17 years presenting to the pediatric ED of a major tertiary care hospital with MBH-related concerns from March 2017 to September 2020. We evaluated trends in MBH ED visits over the study period, specifically comparing patient demographics, diagnosis categories, and ED disposition between the pre-COVID (2019) and COVID (2020) periods using pairwise Pearson χ2 analyses with reported odds ratios (ORs) in SAS statistical software version 9.4 (SAS Institute Inc, Cary, NC).ResultsOf 8093 MBH-related visits, 58.5% were females, 85.4% were adolescents, and 62.7% self-identified as non-Hispanic. The proportion of MBH-related ED visits increased from 3.8% to 7.5% over the study period (P < 0.0001). Although total MBH visits decreased by 17.3% from 2019 to 2020, there was a proportionate increase in MBH-to-total-ED visits, representing a 42.8% increase through 2019. Compared with 2019, there was a proportionate increase in MBH-related ED visits by females (10.6%, P < 0.0001), older adolescents (18.2%, P < 0.0001), and non-Hispanic patients (6.1%, P = 0.017) in 2020. The MBH visits in 2020 were more likely related to suicidality/self-harm (OR, 1.2; confidence interval [CI], 1.1–1.4) or substance use (OR, 1.4; CI, 1.1–1.9). Compared with 2019, there were significantly higher odds of admission (OR, 1.6; CI, 1.3–2.1) or transfer for inpatient psychiatric care (OR, 1.8; CI, 1.6–2.1) in 2020.ConclusionsOur data suggest that the early COVID-19 pandemic had a significant impact on MBH-related ED visits. Compared with 2019, we observed a significant increase in the proportion of MBH-to-total-ED visits primarily affecting older adolescent, non-Hispanic girls with suicidality/self-harm and substance-related disorders in 2020, despite an overall decrease in the number of MBH visits during this period. There was also an increase in the proportion of visits resulting in admission or transfer for inpatient psychiatric care in 2020.

Integrating Google Trends Search Engine Query Data Into Adult Emergency Department Volume Forecasting: Infodemiology Study.

The search for health information from web-based resources raises opportunities to inform the service operations of health care systems. Google Trends search query data have been used to study public health topics, such as seasonal influenza, suicide, and prescription drug abuse; however, there is a paucity of literature using Google Trends data to improve emergency department patient-volume forecasting. We assessed the ability of Google Trends search query data to improve the performance of adult emergency department daily volume prediction models. Google Trends search query data related to chief complaints and health care facilities were collected from Chicago, Illinois (July 2015 to June 2017). We calculated correlations between Google Trends search query data and emergency department daily patient volumes from a tertiary care adult hospital in Chicago. A baseline multiple linear regression model of emergency department daily volume with traditional predictors was augmented with Google Trends search query data; model performance was measured using mean absolute error and mean absolute percentage error. There were substantial correlations between emergency department daily volume and Google Trends "hospital" (r=0.54), combined terms (r=0.50), and "Northwestern Memorial Hospital" (r=0.34) search query data. The final Google Trends data-augmented model included the predictors Combined 3-day moving average and Hospital 3-day moving average and performed better (mean absolute percentage error 6.42%) than the final baseline model (mean absolute percentage error 6.67%)-an improvement of 3.1%. The incorporation of Google Trends search query data into an adult tertiary care hospital emergency department daily volume prediction model modestly improved model performance. Further development of advanced models with comprehensive search query terms and complementary data sources may improve prediction performance and could be an avenue for further research.

Prognostication in Acute Neurological Emergencies

BackgroundFor patients with acute, serious neurological conditions presenting to the emergency department (ED), prognostication is typically based on clinical experience, scoring systems and patient co-morbidities. Because estimating a poor prognosis influences caregiver decisions to withdraw life-sustaining therapy, we investigated the consistency of prognostication across a spectrum of neurology physicians. MethodsFive acute neurological presentations (2 with large hemispheric infarction; 1 with brainstem infarction, 1 with lobar hemorrhage, and 1 with hypoxic-ischemic encephalopathy) were selected for a department-wide prognostication simulation exercise. All had presented to our tertiary care hospital's ED, where a poor outcome was predicted by the ED neurology team within 24 hours of onset. Relevant clinical, laboratory and imaging data available before ED prognostication were presented on a web-based platform to 120 providers blinded to the actual outcome. The provider was requested to rank-order, from most to least likely, the predicted 90-day modified Rankin Scale (mRS) score. To determine the accuracy of individual outcome predictions we compared the patient's the actual 90-day mRS score to highest ranked predicted mRS score. Additionally, the group's “weighted” outcomes, accounting for the entire spectrum of mRS scores ranked by all respondents, were compared to the actual outcome for each case. Consistency was compared between pre-specified provider roles: neurology trainees versus faculty; non-vascular versus vascular faculty. ResultsResponses ranged from 106-110 per case. Individual predictions were highly variable, with predictions matching the actual mRS scores in as low as 2% of respondents in one case and 95% in another case. However, as a group, the weighted outcome matched the actual mRS score in 3 of 5 cases (60%). There was no significant difference between subgroups based on expertise (stroke/neurocritical care versus other) or experience (faculty versus trainee) in 4 of 5 cases. ConclusionAcute neuro-prognostication is highly variable and often inaccurate among neurology providers. Significant differences are not attributable to experience or subspecialty expertise. The mean outcome prediction from group of providers (“the wisdom of the crowd”) may be superior to that of individual providers.

Characteristics, reasons and patterns of Road Traffic Injuries presenting in emergency department of a tertiary care public hospital in Karachi.

Objectives:To determine the main characteristics, reasons and patterns of road traffic injuries (RTIs) in a tertiary care public hospital of Karachi.Methods:It was a hospital based cross sectional study conducted in a public tertiary care hospital emergency department with a sample size 425 selected conveniently. Participants included the consenting victims or caretaking attendants of road traffic injuries (RTIs) from 25th May to 28th June in 2019. A structured questionnaire was developed after literature review and was translated into “Urdu” language. The questionnaire collected detailed information on socio-demographic characteristics, possible reasons of RTI’s such as condition of vehicle, over speeding and breaking traffic rules. Data was analyzed by using software SPSS version 20.Results:Almost half of RTI victims (43.1%) belonged to the age group 18-29. Majority of the victims were males (86.6%). The most common vehicle involved was motorbike (87.50%) followed by Rickshaw (6.8%) and Car (2.4%). Majority of RTIs occurred on main road (75.30%). The most common sites of injuries were lower limb (64%), upper limb (37.60%) and head (32.2%). The severe injuries were significantly more likely to happen in events in which direct collision with other vehicle/thing was involved, road conditions were wet and pedestrian were crossing the road.Conclusion:Motorbikes were involved in majority of RTIs. Main reasons of RTIs included irresponsible road behaviors including over-speeding, careless road crossing, breaking the signal and riding on wet roads which lead to moderate to severe injuries in almost two thirds of participants

The impact of emergency department crowding on admission decisions and patient outcomes.

The objective of this study is to evaluate the impact of emergency department (ED) crowding levels on patient admission decisions and outcomes. A retrospective study was performed based on 2-year electronic health record data from a tertiary care hospital ED in Alberta, Canada. Using modified Poisson regression models, we studied the association of patient admission decisions and 7-day revisit probability with ED crowding levels measured by: 1) the total number of patients waiting and in treatment (ED census), 2) the number of boarding patients (boarder census), and 3) the average physician workload, calculated by the total number of ED patients divided by the number of physicians on duty (physician workload census). The control variables included age, gender, treatment area, triage level, and chief complaint. A subgroup analysis was performed to evaluate the heterogeneous effects among patients of different acuity levels. Our dataset included 141,035 patient visit records after cleaning from August 2013 to July 2015. The patient admission probability was positively correlated with ED census (relative risk [RR]=1.006, 95% confidence interval [CI]=1.005 to 1.007) and physician workload census (RR=1.029, 95% CI=1.027 to 1.032), but inversely correlated with boarder census (RR=0.991, 95% CI=0.989 to 0.993). We further found that the 7-day revisit probability of discharged patients was positively associated with boarder census (RR=1.009, 95% CI=1.004 to 1.014). Patient admission probability was found to be directly associated with ED census and physician workload census, but inversely associated with the boarder census. The effects of boarder census and physician workload census were stronger for patients of triage levels 3-5. Our results suggested that (i) insufficient physician staffing may lead to unnecessary patient admissions; (ii) too many boarding patients in ED leads to an increase in unsafe discharges, and as a result, an increase in 7-day revisit probability.

Implementation of the Abbott ID Now COVID-19 assay at a tertiary care center: a prospective pragmatic implementation study during the third wave of SARS-CoV-2 in Ontario

The Abbott ID Now COVID-19 assay is a point-of-care molecular diagnostic tool for the detection of SARS-CoV-2. We prospectively monitored implementation of the assay in a tertiary care hospital emergency department (ED) for the diagnosis of early symptomatic patients. A total of 269 paired nasopharyngeal swabs were tested in parallel with the ID Now and laboratory-based molecular methodologies, 191 of which met selection criteria for testing based on symptoms description and duration. Forty-six and 48 samples were positive for SARS-CoV-2 with the ID Now and reference molecular assays respectively. Percent positive and negative agreement were high (93.8% and 99.6% respectively), as were the sensitivity and specificity (93.8% and 99.5%). ID Now results were available 17.47 hours earlier than qRT-PCR. In symptomatic patients seen in ED within 7 to 10 days of symptoms onset, the ID Now COVID-19 assay allows for rapid and accurate detection of infection.

SARS-CoV-2 Antigen Detection to Expand Testing Capacity for COVID-19: Results from a Hospital Emergency Department Testing Site.

Background: SARS-CoV-2 antigen detection has currently expanded the testing capacity for COVID-19, which yet relies on the SARS-CoV-2 RNA RT-PCR amplification. Objectives: To report on a COVID-19 testing algorithm from a tertiary care hospital emergency department (ED) that combines both antigen (performed on the ED) and RT-PCR (performed outside the ED) testing. Methods: Between December 2020 and January 2021, in a priori designated, spatially separated COVID-19 or non-COVID-19 ED areas, respectively, symptomatic or asymptomatic patients received SARS-CoV-2 antigen testing on nasopharyngeal swab samples. Antigen results were promptly accessible to guide subsequent, outside performed confirmatory (RT-PCR) testing. Results: Overall, 1083 (100%) of 1083 samples in the COVID-19 area and 1815 (49.4%) of 3670 samples in the non-COVID-19 area had antigen results that required confirmation by RT-PCR. Antigen positivity rates were 12.4% (134/1083) and 3.7% (66/1815), respectively. Compared to RT-PCR testing results, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of antigen testing were, respectively, 68.0%, 98.3%, 88.8%, and 94.1% in the COVID-19 area, and 41.9%, 97.3%, 27.3%, and 98.6% in non-COVID-19 area. Practically, RT-PCR tests were avoided in 50.6% (1855/3670) of non-COVID-19 area samples (all antigen negative) from patients who, otherwise, would have needed antigen result confirmation. Conclusions: Our algorithm had value to preserve RT-PCR from avoidable usage and, importantly, to save time, which translated into a timely RT-PCR result availability in the COVID-19 area.