Time Of Emergency Department Visit Research Articles

Analysis of the Association between Telomere Length and Neurological Disability in Stroke Types.

Background and Objectives: The association between neurological disability, prognosis, and telomere length (TL) in patients with stroke has been investigated in various ways. However, analysis of the type of stroke and ischemic stroke subgroups is limited. In this study, we aimed to determine the association between TL and neurological disability according to stroke type. Materials and Methods: This prospective study included patients with stroke who visited a single-center emergency department (ED) between January 2022 and December 2023. The association between TL and neurological disabilities, using the Modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS), was evaluated according to the patient's stroke type and subgroup of ischemic stroke. Multivariate analysis was performed to determine the association between neurological disabilities in patients with ischemic stroke and the subgroups. Results: A total of 271 patients with stroke were enrolled. The NIHSS score was found to be higher at the time of ED visit (adjusted odds ratio [OR], 5.23; 95% confidence interval [CI], 1.59-17.2, p < 0.01) and 1 day later (adjusted OR, 7.78; 95% CI, 1.97-30.70, p < 0.01) in the ischemic stroke group with a short TL. In the other determined etiology (OD) or undetermined etiology (UD) group, the NIHSS was higher in the short TL group at the ED visit (adjusted OR, 7.89; 95% CI, 1.32-47.25, p = 0.02) and 1 day after (adjusted OR, 7.02; 95% CI, 1.14-43.47, p = 0.04). Conclusions: TL is associated with neurological disability in early ischemic stroke and is prominent in the UD and OD subgroups.

Key Aspects of Pediatric Liver Transplant Patient Visits to the Pediatric Emergency Department.

Patients with liver transplant can present to a pediatric emergency department with short- and long-term complications of transplant. Here, we described clinical features of pediatric liver transplant patients admitted to the pediatric emergency department and identified risk factors that may lead to pediatric intensive care unit admission. We retrospectively evaluated pediatric liver transplant patients admitted posttransplant to Baskent University Hospital's pediatric emergency department in 2023. We noted symptoms, laboratory tests, hospitalization status, and final diagnoses. We compared clinical and laboratory features of patients admitted or not admitted to the intensive care unit. In 2023, 108 presentations of 33 liver transplant patients presented to our pediatric emergency department: 46.3% were girls, mean age was 7.79 ± 4.40 years, and median posttransplant day at time of emergency department visit was 622 days. Common symptoms were vomiting (48%), fever (46%), and rhinorrhea and cough (34%). Forty-nine visits (45.4%) resulted in hospitalization; 5 visits (4.6%) resulted in PICU admission, with 2 mortalities (1.8%). Final diagnoses included acute gastroenteritis and upper respiratory tract infections (23 patients) and lower respiratory tract infections (13 patients). Seven patients had cholangitis, 6 had intra-abdominal infection, and 5 had sepsis. Seizures and sepsis were significantly correlated with intensive care unit admission (P <.001). Patients admitted to the intensive care unit had significantly shorter time posttransplant versus other patients (518 ± 324 vs 1498 ± 1658 days; P < .001). Half of patients who presented to the emergency department required hospitalization mainly for observation and supportive treatment, with a small number requiring intensive care unit admission. Nevertheless, physicians caring for liver transplant patients should be aware of serious complications and monitor patients closely, especially early posttransplant when intensive immunosuppressive treatment regimens are used.

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

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

MP16-04 EFFECTS OF DELAYED SURGICAL INTERVENTION FOLLOWING ED PRESENTATION ON STONE SURGERY COMPLEXITY

You have accessJournal of UrologyCME1 Apr 2023MP16-04 EFFECTS OF DELAYED SURGICAL INTERVENTION FOLLOWING ED PRESENTATION ON STONE SURGERY COMPLEXITY Johsias Maru, Sudarshan Srirangapatanam, Cameron Hicks, Manuel Armas-Phan, Charles Scales, Thomas Chi, Marshall Stoller, and David Bayne Johsias MaruJohsias Maru More articles by this author , Sudarshan SrirangapatanamSudarshan Srirangapatanam More articles by this author , Cameron HicksCameron Hicks More articles by this author , Manuel Armas-PhanManuel Armas-Phan More articles by this author , Charles ScalesCharles Scales More articles by this author , Thomas ChiThomas Chi More articles by this author , Marshall StollerMarshall Stoller More articles by this author , and David BayneDavid Bayne More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003236.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior literature has elucidated increased stone burden and higher rates of staged surgery in individuals of lower socioeconomic status (SES). Low SES individuals are more likely to experience delays in definitive stone surgery after presenting to an emergency department (ED). The objective of this study was to investigate the relationship between delays in definitive surgery for kidney stones and the subsequent need for complex surgical procedures using a statewide dataset. METHODS: In this retrospective cohort study, longitudinal data from 2009-2018 was gathered using the California Department of Health Care Access and Information dataset. Patient characteristics, diagnosis codes, procedure codes and distance were analyzed. Complex stone surgery was defined as initial PNL and/or undergoing more than 1 procedure within 365 days of initial intervention (mean interval between procedures=60 days). RESULTS: A total of 1,816,093 billing encounters from 947,798 patients were screened, resulting in 45,764 patients with ED visits for kidney stones followed by a urologic stone procedure. On multivaraite analysis, relative to patients who underwent surgery within 1 month, there was a significantly increased odds of undergoing complex surgery for patients waiting ≥6 months (OR 1.20, p=0.004), ≥1 year (OR 1.29, p<0.001), and ≥3 years (OR 1.43, p<0.001). Using time as a continuous variable revealed 0.03% increase in odds of undergoing complex surgery for every one day delay in (p<0.001). Insurance status at the time of ED visit was also predictive of complex stone surgery with Medicaid (1.57, 95% CI: 1.46-1.69) and Medicare (OR: 1.28, 95% CI: 1.17-1.41) showing significantly higher odds relative to Private insurance (p<0.001). Living more than 10 miles from the hospital was associated with 11% increase in odds (p<0.001). Each one point increase in CCI was associated with a 10% average increase in odds of undergoing complex surgery (p<0.001). CONCLUSIONS: Delays in surgery for kidney stones are associated with an increased likelihood of undergoing a complex stone treatment. Complex surgery was also more likely among non-privately insured patients, patients living further from the surgery facility, and patients with more comorbidities. Source of Funding: UCSF Department of Urology © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e202 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Johsias Maru More articles by this author Sudarshan Srirangapatanam More articles by this author Cameron Hicks More articles by this author Manuel Armas-Phan More articles by this author Charles Scales More articles by this author Thomas Chi More articles by this author Marshall Stoller More articles by this author David Bayne More articles by this author Expand All Advertisement PDF downloadLoading ...

Clinical factors associated with delayed emergency department visit in intracranial traumatic brain injury: from a multicenter injury surveillance registry

ABSTRACT Introduction Early diagnosis and intervention by visiting the emergency department (ED) are important for traumatic brain injury (TBI). We evaluate the factors associated with delayed ED visits in patients with intracranial TBI. Methods A retrospective multicenter observational study using the ED-based injury in-depth surveillance database (EDIIS) was designed. Patients with intracranial TBI with an alert mentality at ED presentation from 2014 to 2019 were enrolled. Patients were categorized into four groups according to ED visit time after injury (<1 h, 1–3 h, 3–12 h, and >12 h). ED visits after 12 h were defined as delayed ED visits. The factors associated with delayed ED visits were identified using multivariable logistic regression analysis. Results Among 15,620 patients with TBI enrolled in the final analysis, 2,190 (14.0%) visited the ED 12 h after injury. Multivariable analysis identified the following factors as independent predictors for delayed ED visit such as unintentionally struck by or against an object or unintentional fall as a trauma mechanism, injury during ordinary activities, indoor injury, injury during nighttime, winter season, combined subdural hemorrhage and epidural hemorrhage. Conclusion In patients with intracranial TBI with an alert mentality, multiple factors related to patient demographics and injury characteristics were associated with the time interval from injury to ED visit.

Abdominopelvic CT Imaging Findings in the Emergency Department in Patients With HIV Positive Status: Single Institute Experience

ObjectiveTo assess emergency department (ED) abdominopelvic computed tomography (CT) imaging utilization and findings in patients with known human immunodeficiency virus (HIV) positive status. Materials and MethodsA retrospective chart review of imaging, clinical, and laboratory data was performed for HIV positive patients who demonstrated HIV-related findings on abdominopelvic CT imaging performed within the ED. ResultsOne hundred and eighty-eight patients with 522 CT scans of the abdomen and/or pelvis were reviewed. 47 patients with HIV presenting to the ED on 82 separate occasions were included in this study (mean age 43.3 years). Patients presented to the ED with infectious/inflammatory disease (n = 54) or history of HIV-related malignancy or new/worsening HIV-related malignancy (n = 28). The most common findings on abdominopelvic CT were anorectal pathology including anorectal abscess or proctitis (n = 22), followed by colitis (n = 19). Findings of HIV-associated malignancy were less common, including anal/rectal cancer (n = 7), Kaposi's sarcoma (n = 4), and lymphoma (n = 2). At the time of ED visit, 25.6% (n = 21) of patients had acquired immunodeficiency syndrome (AIDS). Higher WBC counts were found in the infectious/inflammatory group (P = 0.021) and patients without AIDS (P = 0.0159), while lower WBC counts were associated with new or worsening malignancy (P = 0.007) and AIDS (P = 0.0000). Patients with AIDS were more likely to be deceased at the time of our study. ConclusionsThe majority of ED visits within our population were attributed to infectious/inflammatory etiologies. CT findings demonstrated predominantly infectious/inflammatory processes, with anorectal pathology being the most common. Findings of malignancy on CT were less common, while opportunistic infections and AIDS-defining malignancies were uncommon.

Emergency department evaluation, treatment, and functional outcomes among patients presenting with low back pain

ObjectivesLow back pain (LBP) leads to more than 4.3 million emergency department (ED) visits annually. Despite the number of ED visits for LBP, emergency medicine societies have not established clear guidelines for the evaluation and care of these patients. This study aims to describe patterns in the evaluation, treatment, and outcomes of patients presenting to an urban, academic ED for atraumatic LBP. MethodsWe prospectively identified a convenience sample of patients presenting with LBP to the University of Utah Hospital ED between January 2017 and June 2018. We collected baseline demographic information and calculated the Patient-Reported Outcomes Measurement Information System Physical Function Short Form 12a (PROMIS PFSF-12a) score to assess patient function and mobility (50 = average PROMIS PFSF-12a score, with higher scores indicating better function). We contacted patients 6 weeks after the ED visit to assess outpatient follow-up and functional outcomes. ResultsOver the 18-month study period, 103 patients presented with a chief complaint of LBP and agreed to participate in the study. Average age of the cohort was 48.5 years (SD = 18.3) and 55 (53.4%) were female. Notably, 61 patients (59.2%) had been seen previously in the ED for LBP and 32 (31.1%) had received an opioid for LBP in the preceding 3 months. In the ED, 35.9% of patient received an opioid while 18.5% had an opioid prescription at discharge. While in the ED, 37 (35.9%) had an x-ray and 47 (45.6%) underwent computed tomography or magnetic resonance imaging. At 6-week follow-up, 22 of 68 (32.4%) patients reported having missed work due to pain. PROMIS PFSF-12a score improved from 32.2 (“low” range) at time of ED visit to 42.0 (“low-average” range) at the 6-week follow up. Regarding outpatient follow-up after the ED visit, 22 patients (21.4%) saw a primary care provider, 12 patients (17.8%) saw orthopedics or neurosurgery, and 8 patients (11.8%) attended physical therapy. ConclusionsPatients receiving ED care for LBP had a significant improvement in PROMIS PFSF-12a scores 6 weeks after the ED but return to function continued to lag despite interventions. Imaging patterns, medication prescriptions, and outpatient follow-up varied widely, emphasizing the needs for clear guidelines and treatment pathways for ED patients with LBP.

Pain-driven emergency department visits and food insecurity: a cross-sectional study linking Canadian survey and health administrative data.

Background:As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals’ pain-driven emergency department visits.Methods:We designed a cross-sectional study linking the Canadian Community Health Survey 2005–2017 to the National Ambulatory Care Reporting System 2003–2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest–throat pain, abdomen–pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non–pain-driven emergency department visits in the models.Results:The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20–1.68), 1.64 (95% CI 1.37–1.96) and 1.99 (95% CI 1.61–2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits.Interpretation:Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization.

Impact of point-of-care ultrasound on treatment time for ectopic pregnancy.

Point-of-care ultrasound (POCUS) is useful in the evaluation of early pregnancy by confirming intrauterine pregnancy and recognizing hemorrhage from ectopic pregnancy. We sought to determine whether transabdominal POCUS by itself or in conjunction with consultative radiology ultrasound (RADUS), reduces Emergency Department (ED) treatment time for patients with ectopic pregnancy requiring operative care, when compared to RADUS alone. A secondary objective was to determine whether the incorporation of POCUS reduces time to operative care for patients with ruptured ectopic pregnancy specifically, when compared to RADUS alone. We performed a retrospective review of patients admitted for operative management of ectopic pregnancy. We excluded patients with known ectopic pregnancy and/or imaging prior to arriving to the treatment area, found not to have an ectopic pregnancy, or did not undergo operative care. Descriptive statistics, classical and nonparametric statistical analysis, and linear regression were performed. There were 220 patients admitted with ectopic pregnancy, 111 met exclusion criteria, yielding 109 for analysis. Of 109, 36 received POCUS (23/36 also had RADUS), while 73 received RADUS only. Among the POCUS group 31/36 (86%) were classified as ruptured versus 47/73 (64%) in the RADUS group. The average ED treatment time in the POCUS group for all admitted ectopic pregnancies was 157.9 min (standard deviation [SD] 101.3) versus 206.3 min (SD 76.6) in the RADUS group (p = 0.0141). The median time to operating room (OR) for ruptured ectopic pregnancies was 203.0 min (interquartile range [IQR] 159.0) in the POCUS group versus 293.0 min (IQR 139.0) in the RADUS group (p = 0.0002). Regression analysis of the primary outcome was limited by multiple interactions and sample size. When controlling for race, positive shock index and ED visit time, POCUS was found to be associated with a significantly shorter time to OR among ruptured ectopic pregnancies compared to RADUS (p = 0.0052). Compared to RADUS alone, incorporation of POCUS was associated with significantly faster ED treatment time for all ectopic pregnancies and significantly faster time to OR for ruptured ectopic pregnancies, even when combined with RADUS. When controlling for clinical differences, time to OR was still faster for patients who underwent POCUS. The integration of POCUS should be considered to expedite care for patients with ectopic pregnancy requiring operative care.

29 Caregiver-Reported Delay in Presentation to Pediatric Emergency Departments for Fear of Contracting COVID-19: A multinational cross-sectional study

Primary Subject areaPublic Health and Preventive MedicineBackgroundVisits to pediatric emergency departments have decreased up to 75% during the pandemic, with corresponding increases in high acuity visits, inpatient admissions, and intensive care unit admissions compared to historical cohorts.ObjectivesTo determine if caregivers of children presenting to pediatric emergency departments (EDs) during the COVID-19 pandemic are delaying presenting to care for fear of contracting COVID-19. Secondary objectives were to: a) evaluate potential predictors of delay; b) describe the proportion of children whose symptoms worsened during time to presentation.Design/MethodsA multicentre cross-sectional survey study of caregivers accompanying their children aged 0-19 years old to 16 pediatric EDs in 6 countries, from May-June 2020. An anonymous online survey, completed by caregivers via RedCAP, included caregiver and child demographics, presenting complaints, if they delayed presentation and whether symptoms worsened during this interval, as well as caregiver concerns about the child or caregiver having COVID-19 at the time of ED visit.ResultsOf 1543 caregivers completing the survey, 287 (18.6%) reported a delay in seeking ED care due to concerns of contracting COVID-19 in the hospital. Of those, 124 (43.2%) stated their child’s symptoms worsened during the waiting interval. Caregiver relationship to child [mother] (OR 1.85, 95% CI 1.27-2.76), presence of chronic illness in child (OR 1.78. 95% CI 1.14-2.79), younger age of caregiver (OR 0.965, 95% CI 0.943-0.986), and caregiver concerns about lost work during the pandemic (OR 1.08, 95% CI 1.04-1.12), were independently associated with a COVID-19-related delayed presentation in multivariate regression analysis.ConclusionAlmost one in five caregivers reported delaying ED presentation for their ill or injured child, specifically due to fear of contracting COVID-19 while in hospital. Mothers, younger caregivers, caregivers of children with chronic illness, and those concerned about lost work were at highest risk for delay.

Urinary Proadrenomedullin and Disease Severity in Children With Suspected Community-acquired Pneumonia.

Plasma proadrenomedullin (proADM) is a promising biomarker to predict disease severity in community-acquired pneumonia (CAP). Urinary biomarkers offer advantages over blood, including ease of collection. We evaluated the association between urinary proADM and disease severity in pediatric CAP. We performed a prospective cohort study of children 3 months to 18 years with CAP. Urinary proADM/creatinine (Cr) was calculated. Disease severity was defined as: mild (discharged home), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with supplemental oxygen and complicated pneumonia) and severe (eg, vasopressors and invasive ventilation). Outcomes were examined using logistic regression within the cohort with suspected CAP and in a subset with radiographic CAP. Of the 427 children included, higher proADM/Cr was associated with increased odds of severe disease compared with nonsevere disease [suspected CAP, odds ratio (OR) 1.02 (95% confidence interval (CI) 1.003, 1.04); radiographic CAP, OR 1.03 (95% CI 1.01, 1.06)] when adjusted for other covariates. ProADM/Cr had an area under the receiver operating characteristic curve of 0.56 (threshold 0.9 pmol/mg) to differentiate severe from nonsevere disease in suspected CAP and 0.65 in radiographic CAP (threshold 0.82 pmol/mg). Healthy controls had less proADM in their urine (median, 0.61 pmol/mg) compared with suspected (0.87 pmol/mg, P = 0.018) and radiographic (0.73 pmol/mg, P = 0.016) CAP. Urinary proADM/Cr ratio measured at the time of emergency department visit was statistically associated with the development of severe outcomes in children with CAP, with stronger discriminatory performance in radiographic disease.

Impact of an emergency department resident strike during the coronavirus disease 2019 (COVID-19) pandemic in Daegu, South Korea: a retrospective cross-sectional study.

BackgroundTo prepare for future work stoppages in the medical industry, this study aimed to identify the effects of healthcare worker strikes on the mortality rate of patients visiting the emergency department (ED) at six training hospitals in Daegu, South Korea.MethodsWe used a retrospective, cross-sectional, multicenter design to analyze the medical records of patients who visited six training hospitals in Daegu (August 21–September 8, 2020). For comparison, control period 1 was set as the same period in the previous year (August 21–September 8, 2019) and control period 2 was set as July 1–19, 2020. Patient characteristics including age, sex, and time of ED visit were investigated along with mode of arrival, length of ED stay, and in-hospital mortality. The experimental and control groups were compared using t-tests, and Mann-Whitney U-test, chi-square test, and Fisher exact tests, as appropriate. Univariate logistic regression was performed to identify significant factors, followed by multivariate logistic regression analysis. ResultsDuring the strike period, 31,357 patients visited the ED, of which 7,749 belonged to the experimental group. Control periods 1 and 2 included 13,100 and 10,243 patients, respectively. No significant in-hospital mortality differences were found between strike periods; however, the results showed statistically significant differences in the length of ED stay. ConclusionThe ED resident strike did not influence the mortality rate of patients who visited the EDs of six training hospitals in Daegu. Furthermore, the number of patients admitted and the length of ED stay decreased during the strike period.

Characteristics and Outcomes of Pediatric Patients With a Ventricular Assist Device Presenting to the Emergency Department.

A growing number of children receive support from left ventricular assist devices (LVADs) in the outpatient setting. Unexpected complications of LVAD support occur that require emergent management, and no studies examine how pediatric LVAD patients present to the emergency department (ED). The goals of this study were (1) to describe frequency of visits, clinical characteristics, adverse events, and outcomes of LVAD-supported children treated in ED settings and (2) to evaluate for associations between specified patient outcomes and ED care location. This was a retrospective cohort study of children in a single-center outpatient VAD program who presented to several EDs during a 10-year period. We defined adverse events according to the Advanced Cardiac Therapies Improving Outcomes Network registry guidelines. Secondary analysis evaluated for associations between specified patient outcomes (adverse events, hospitalizations, intensive care unit admissions) and ED care location (institutional vs other ED). Of 104 subjects with LVAD implantations during the study period, 30 (28.8%) transitioned to outpatient care. Among subjects in the outpatient VAD program, 24 (80%) of 30 had 54 visits to various EDs over 141.9 patient-months. The median age at time of ED visit was 13.5 years (range, 7.2-17.9 years). The median number of visits per subject was 1 (range, 0-6). The most common complaints on arrival to the ED were vomiting or abdominal pain (16.7%), fever (15.3%), and headache (13.9%). Seventeen adverse events occurred during 14 (25.9%) of 54 ED visits. The most common adverse events were major infection (33.3%) and right heart failure (16.7%). Hospital admission resulted from 41 (75.9%) of 54 ED visits, including 17 (41.5%) of 41 to a cardiovascular intensive care unit. Care at a nonspecialty ED was associated with a higher rate of hospitalization (93.8% vs 68.4%, P = 0.049). During the study period, 4 subjects (13.3%) died, including 1 patient on destination therapy, 1 with multisystem organ failure due to cardiogenic shock, and 2 with hemorrhagic stroke. No patient died while in the ED. Among subjects in a single outpatient pediatric VAD program presenting to the ED, the most common complaints were abdominal pain/vomiting, fever, and headache. The most common adverse events were major infection and right heart failure. Subjects had a high rate of ED utilization and hospital admission.

Analysis of reasons for emergency department (ED) visits and resulting hospital admissions in breast cancer patients: A retrospective study from rural cancer center in Maine.

e18682 Background: Reducing ED visits in patients with cancer is cost saving and is particularly relevant during the COVID pandemic. Methods: We analyzed the number of ED visits occurred in our breast cancer population between July 1 2019 and August 31 2020 including demographics, stage distribution, treatment type within the month of ED visit, reason, time of the day, day of the week the visit occurred. Results: A total of 101 patients had 162 visits. 38 (38%) had more than 1 ED visit. Majority (36%) had stage 4 disease at the time of ED visit. The top 5 reasons for ED visits were fall and injury (N=30), GI (N=24), cardiac (N=17), respiratory symptoms (N=14) and cancer related pain (N=11). The median age in patients with ED visit due to fall injury/pain was 75 and non-fall injury/pain was 55 years. The most common reasons for chemotherapy induced ED visits were GI related (N=8) and Neutropenic fever (N=7). Cyclophosphamide/doxorubicin was the common regimen associated with neutropenic fever. A total of 72 (44%) visits resulted in hospital admissions. Most common symptom categories requiring hospital admissions were cardiac (82.3%), sepsis/cellulitis (81.8%), respiratory (64%), cancer related pain (54.5%) and GI (50%). Most were on endocrine therapy at the time of their visit (N= 59) and 31 were on no treatment at all. Falls were unrelated to disease or treatment and occurred in patients above age 70. Visits occurred during working hours from 6AM to 5PM, with peak incidence on Mondays and Fridays. Conclusions: Reducing ED visit in cancer patients is a worthwhile endeavor particularly in the context of the COVID pandemic. The main reason for ED visits were falls and injuries that were unrelated to disease or treatment in breast cancer patients. As a result, we are implementing systematic physical therapy assessment for our breast cancer population over age of 60 at our cancer center and call us first campaign, to get an opportunity to intervene prior to going to the ED as majority of the ED visits occurred during working hours.[Table: see text]

Effect of the COVID-19 pandemic during the first lockdown in the Netherlands on the number of trauma-related admissions, trauma severity and treatment: the results of a retrospective cohort study in a level 2 trauma centre

ObjectivesTo determine the impact of the first lockdown in the Netherlands’ measures during the COVID-19 pandemic on the number and type of trauma-related injuries presenting to the emergency department (ED).DesignA...

From metrics to practice: identifying preventable emergency department visits for patients with cancer.

Oncology patients disproportionately utilize the emergency department (ED) for symptom management. At our institution, approximately 1 in 4 visits to the ED by oncology patients led to discharge. We hypothesized that many of the visits leading to ED discharge would be potentially preventable (PP). We retrospectively characterized ED discharges of oncology patients. Visits were classified by presenting symptom, type of cancer, and time of ED visit. Chart reviewers were additionally asked whether each case could have been safely managed as an outpatient. We analyzed 100 ED discharges in a 4-month period in 2016 and 2017. Gastrointestinal (GI) complaints, pain, and fever were the most common presenting symptoms for these visits. We rated 44 of 100 ED discharges as potentially preventable. Given we analyzed only ED discharges which comprise about 25% of ED visits for patients with cancer, overall about 10% of all ED visits by these patients may be preventable. We also found that ED visits without a clinic appointment or phone call to the clinic on the day of ED presentation were more likely to be preventable (51% vs 27%, OR 2.9, p = 0.026). Many ED visits by oncology patients may be preventable and occur for symptoms which can be managed as an outpatient. More of these visits also appear to occur in those who do not reach a clinic member prior to the visit. These findings suggest that improved access to clinics and standardized outpatient symptom management are next steps to consider in preventing ED visits in this vulnerable population.

288 Characteristics and Outcomes of Patients with Ventricular Assist Devices Presenting to a Pediatric Emergency Department

Ventricular assist devices (VADs) are being used more frequently in pediatric patients with advanced heart failure. Outpatient management of children with VAD implantations also is becoming more common. However, no study exists that describes Emergency Department (ED) care of these patients. This study aims to identify patient characteristics and outcomes of children with VADs presenting to the ED. This is a retrospective descriptive study of all patients ages 0 to 18 years in the Stanford Children’s outpatient VAD program who presented to our pediatric ED between 2010 (year of first discharged VAD patient) and 2020. Patient data was abstracted from electronic medical records. Adverse events were defined according to the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry guidelines. Adverse events were included if they occurred during the ED visit or associated hospitalization. A total of 30 children with VAD implantations were transitioned to outpatient care in the study period. All were implanted with continuous flow devices. Among children in the outpatient VAD program, 20/30 (66.7%) had 38 visits to our pediatric ED over 141.5 patient-months. Median age of patients at time of ED visit was 12.5 (range 7.3-17.4) years. Median number of ED visits per discharged child was 1 (range 0-4). The most common complaints on arrival to ED included fever (7/38; 18.4%), abdominal pain or vomiting (7/38; 18.4%), headache (6/38; 15.8%), bleeding from any site (4/38; 10.5%), chest pain (4/38; 10.5%), device malfunction or alarm (3/38; 7.9%), dizziness (3/38; 7.9%), and dyspnea (3/38; 7.9%). Adverse events occurred during 14/38 (36.8%) ED visits or associated hospitalizations, including 3/38 (7.9%) instances each of hypertension, major infection, or right heart failure, 2/38 (5.3%) instances of major bleeding, and 1/38 (2.6%) instances each of hemolysis, renal dysfunction, or device malfunction. Hospital admission occurred in 27/38 (71.1%) of visits, including 10/27 (37.0%) to a cardiac intensive care unit. No patients died during an ED visit or associated hospitalization. Mortality of all children in the outpatient VAD program during the study period was 3/30 (10.0%) including one patient on destination therapy, one with hemorrhagic stroke, and one with multi-system organ failure due to cardiogenic shock. In a single outpatient pediatric VAD program, patients had high utilization of ED care and had a high rate of hospital admission following ED presentation. The youngest patient transitioned to outpatient VAD care was 7 years old. Fever, abdominal pain/vomiting, and headache were the most frequent initial complaints. The most common adverse events were hypertension, major infection, and right heart failure.

A comparison of the effect of weather and climate on emergency department visitation in Roanoke and Charlottesville, Virginia

Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010–2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age.The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females.The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.

Investigation of Whole Spine MRI in the Emergency Department at Two Large Tertiary Care Academic Medical Centers in the United States

Rationale and ObjectivesThe impact of emergent whole spine magnetic resonance imaging (WS-MRI) on patient management has not been extensively studied to date. Here, we explore indications, results, and outcomes associated with WS-MRI performed through the emergency departments (EDs) of 2 large tertiary care, academic medical centers in the Northeastern United States. We hypothesize that given a relatively low barrier to entry, coupled with lack of appropriateness guidelines, a sizeable proportion of WS-MRI studies performed emergently do not result in spine findings necessitating inpatient admission for immediate treatment. Materials and MethodsWe retrospectively studied 335 adult patients (≥18 years) who underwent WS-MRI through the ED between 2016 and 2019. The demographic data collected included, age, sex, chief complaint, history of spine disease, and date and type of last spine imaging prior to ED presentation. Data compiled from the time of ED visit included WS-MRI result and patient disposition, including reason for hospital admission, by which patients were categorized into groups to allow for ease of comparisons. Hypergeometric tests were used to determine statistically significant associations between random discrete variables. ResultsTrauma was the most frequent chief complaint, comprising 35% (n = 117) of all presentations, followed by pain (25%, n = 84), motor deficit (16%, n = 55), sensory disturbance (12%, n = 41), bowel, and/or bladder dysfunction (9%, n = 30), and subjective or objective fevers with suspicion for spine infection (2%, n = 8). The largest proportion of WS-MRI studies revealed degenerative disc disease (DDD) as the principal result (41%, n = 139). 52% of all patients were either discharged directly from the ED (41%) or admitted for a non-spine issue after WS-MRI (11%); of these numbers, 61% underwent WS-MRI and no other imaging study in the ED. In patients who presented with a chief complaint of pain, DDD was often the principal WS-MRI finding (54%), albeit this association was not statistically significant. DDD, nonetheless, was positively associated with a discharge from the ED (P <0.001). Trauma was positively associated with fracture or ligamentous/soft tissue injury (P <0.001) on WS-MRI and hospital admission for a spine issue (P <0.01). ConclusionThat just under half of patients in our study were admitted for spine-related pathology suggests that WS-MRI is valuable in the emergent setting. At the same time, however, that over half of patients were not subsequently admitted for a spine-related issue points to the possibility of further refining which patients would benefit most from WS-MRI. WS-MRI may be less helpful in patients presenting with pain, though may be higher-yield in those with trauma, motor deficits, and bowel/bladder complaints. Although MRI is highly sensitive in ruling out emergent central nervous system pathology, given the resource-intensive nature of the test, it is prudent to carefully select which patients should undergo emergent WS-MRI, especially in instances when more cost-effective, alternative diagnostic approaches, including detailed neurological exam, computed tomography, or localized/targeted MRI, are possible.

The growing impact of older patients in the emergency department: a 5-year retrospective analysis in Brazil

BackgroundThe average age of the global population is rising at an increasing rate. There is a disproportional increase in Emergency Department (ED) visits by older people worldwide. In the Brazilian health system, complex and severely ill patients and those requiring specialized urgent procedures are referred to tertiary level care. As far as we know, no other study in Latin America has analyzed the impact of demographic changes in tertiary ED attendance. Aim: To describe the sociodemographic characteristics and outcomes of tertiary Brazilian ED users.MethodsDesign: Observational cross-sectional analytic study. Setting: Emergency Department, tertiary university hospital, São Paulo, Brazil. Participants: patients aged 18 years or older attending a tertiary ED (2009–2013). The primary outcomes were hospitalization and mortality; the secondary outcome was ICU admission. Age was categorized as ‘young adults’ (18-39y), ‘adults’ (40-59y), ‘young-older adults’ (60-79y), and ‘old-older adults’ (80-109y). Other variables included sex, reason for attendance, time of ED visit, mode of presentation, type of hospitalization, main procedure, length of hospital stay (LOS) and length of ICU stay (ICU-LOS). We calculated descriptive statistics, built generalized linear mixed models for each outcome and estimated Odds Ratios (95% CI) for the independent categorical variables. The significance level was 5% with Bonferroni correction.ResultsOlder age-groups represented 26.6% of 333,028 ED visits, 40.7% of admissions, 42.7% of ICU admissions and 58% of all deaths. Old-older patients accounted for 5.1% of ED visits, 9.5% of admissions and 10.1% of ICU admissions. Hospitalization, ICU admission and mortality rates increased with older age in both sexes. LOS and ICU-LOS were similar across age-groups. The proportions of visits and admissions attributed to young adults decreased annually, while those of people aged 60 or over increased. The ORs for hospitalization, ICU admission and mortality associated with the old-older group were 3.49 (95% CI = 3.15–3.87), 1.27 (1.15–1.39) and 5.93 (5.29–6.66) respectively, with young adults as the reference.ConclusionsIn tertiary ED, age is an important risk factor for hospitalization and mortality, but not for ICU admission. Old-older people are at the greatest risk and demand further subgroup stratification.