Urban ED Research Articles

Computed tomography pulmonary angiogram ordering, adherence to decision rules and yield in the emergency department: An observational study.

Pulmonary embolism (PE) frequently requires diagnosis through CT pulmonary angiogram (CTPA). Appropriate application of evidence-based clinical decision tools can reduce unnecessary CTPAs. This study assessed adherence to and the efficacy of various aspects of the Queensland Health suspected PE diagnostic pathway, including Wells score, PE rule out criteria (PERC) and age-adjusted D-dimer interpretation. Retrospective study of CTPAs ordered from 1 January to 30 April 2023 in a tertiary and urban ED in Southeast Queensland. Data on clinical variables, D-dimer and CTPA results were collected through medical record and radiology database review. Descriptive analyses were used to determine adherence to Queensland guidelines and performance of D-dimer interpretation tools (including comparison of age-adjusted PE with a new pre-test probability [PTP]-based model using D-dimer cut-off <1000 ng/mL for Wells score ≤4 and 500 ng/mL for Wells score 4.5-6). A total of 573 CTPAs were available for analysis with a 12.4% (95% confidence interval 10.0-15.4) diagnostic yield. Stratification by Wells score showed yields of 4.0%, 18.5% and 41% for low-, moderate- and high-risk patients, respectively. Twenty-five patients with low-PTP who received CTPA could have been excluded with the PERC rule. Age-adjusted D-dimer interpretation may have prevented 26 CTPAs with no false negatives, whereas PTP approach may have prevented 128 CTPAs with four false negatives. Guideline adherence can be improved, and adherence to existing clinical decision tools may reduce unnecessary CTPA ordering and increase diagnostic yield. The use of the age-adjusted D-dimer had good sensitivity, whereas the new PTP approach will require further prospective research.

Impact of Health Link utilization on emergency department visits.

Our aim was to compare Health Link utilization in urban and rural Alberta by metrics relevant to the ED. Data on Health Link callers from January 1, 2018-December 31, 2019 was extracted from the National Ambulatory Care Reporting System, including postal code, location of ED attended, Canadian Triage Acuity Scale (CTAS) assigned at ED, age, and self-identified gender. Usage density (presentations/100/year), patient demographics (age, self-identified gender), and ED metrics (CTAS, investigations, admission) were compared for Health Link ED referrals and direct ED visits. In this period, 900,196 individuals called Health Link, 241,103 were referred to the ED, 58% (140,614) of which presented to the ED within 24h of their call. These referrals constituted 3.4% of the total ED visit population (4,194,735). Looking at the density of ED utilization, this is greater in rural than urban settings with respect to patients who present directly to the ED (90.9 vs. 36.5 presentations/100/year). There is a sparser density of Health Link ED visits in rural settings than in urban centres (1.5 vs. 1.6). Urban ED presentations were more often triaged as a CTAS 1-3 than a CTAS 4-5 if they had presented after a Health Link referral (76.0% CTAS 1-3) than a direct ED visit (63.0% CTAS 1-3). This effect is greater for rural patients, who also more likely to present as a CTAS 1-3 than a CTAS 4-5 if they were referred through Health Link (61.1% CTAS 1-3) compared to those who directly went to the ED (39.0% CTAS 1-3). This study on Health Link describes how tele-health can often triage higher acuity patients to appropriately receive ED level care, which may be important for future development of health care and ED infrastructure.

Paired analysis of ED efficiency for low-acuity children treated by PAs and pediatricians.

To determine if there was a clinically important difference (15 minutes or more) in length of stay (LOS) for low-acuity pediatric ED patients treated by PAs compared with those treated by pediatricians. Between July 2017 and February 2020, shifts were identified that had shared PA and pediatrician staffing in the low-acuity care area for a large, urban ED. LOS was collected for every patient during the 6 hours of overlap for each shift. Using a paired analysis, we calculated the difference in mean LOS for these shifts. Mean shift LOS for children seen by PAs (160.1 minutes, SD: 48.6) was 10.1 minutes longer (95% CI: 6.1, 14.1) than mean shift LOS for children seen by pediatricians (150 minutes, SD: 47.3). No clinically important difference in LOS was found for low-acuity children treated by PAs compared with those treated by pediatricians in a large, urban ED.

Piloting a novel medical student virtual discharge counseling process in the time of the COVID-19 pandemic

Background During the COVID-19 pandemic, we identified a gap in adequate discharge counseling for COVID-19 patients in the Emergency Department. This was due to high patient volumes and lack of patient education regarding a novel disease. Medical students were also restricted from clinical areas due to safety concerns, compromising their clinical experience. We piloted a novel program in which medical students served as virtual discharge counselors for COVID-19 patients via teleconference. We aimed to demonstrate an impact on patient care by examining the patient bounce back rate as well as assessing medical student education and experience. Methods This program was piloted in a tertiary care Emergency Department. Medical student volunteers served as virtual discharge counselors. Students were trained in discharge counseling with a standardized protocol and a discharge script. Eligible patients for virtual discharge counseling were 18 years old or greater with a diagnosis of confirmed or suspected COVID-19 and no impediment precluding them from participating in a telemedicine encounter. Counseling was provided via secure teleconference in the patient's preferred language. Counseling included diagnosis, supportive care with medication dosing, quarantine instructions, return precautions, follow up, and time to ask questions. Duration of counseling was recorded and medical students were anonymously surveyed regarding their experience. Results Over an 18-week period, 45 patients were counseled for a median of 20 min. The 72-hr ED revisit rate was 0%, versus 4.2% in similarly-matched, not counseled COVID-19 patients. 90% of medical students believed this project increased their confidence when speaking with patients while 80% indicated this was their first telemedicine experience. Conclusion Our pilot discharge program provided patients with an extensive discharge counseling experience that would not otherwise be possible in an urban ED setting and demonstrated benefit to patient care. Medical students received a safe clinical experience that improved their communication skills.

Abstract 104: Taurine As Biomarker And Therapeutic Target For Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (CA) is a leading cause of death with high mortality. Most patients die from post-CA syndrome due to ischemia/reperfusion injury-triggered responses. Taurine and glutamate, amino acids with cellular activities that are expressed primarily in heart and brain tissues, respectively, are released in response to CA. Hypothesis: Taurine and glutamate levels in blood reflect the extent of injury of CA. Taurine and glutamate could potentially regulate CA outcomes. Methods: Adult CA patients (n=51, 19 survivors, S and 32 nonsurvivors, NS; 35 received cooling treatment, C while 16 did not, NC) at an urban academic ED were enrolled from 2018-2019. Plasma taurine and glutamate collected at various time points including hospital arrival, 6, 24, 48 and 72 hours after arrival, and measured with commercially available assay kits. In a mouse model, 8-min asystolic cardiac arrest was induced with KCl, followed by initiation of CPR and randomized to blinded administration of taurine (50 mg/kg) or saline placebo at 90 second during CPR. Survival (4h) and mean arterial blood pressure (MAP) were evaluated. The Wilcoxon test and generalized estimating equation were used for comparison at each time point and longitudinal trend analysis for human data. Kaplan-Meier estimate and T-test were used for survival and mean comparison in mice. p &lt;0.05 was considered statistically significant. Results: Plasma taurine and glutamate levels were highest at R0 and decreased over time in both S and NS, and were higher in NS than S. Taurine levels were significantly associated with survival (NS 66.24±41.36 vs. S 37.48±19.46 at 6h, p &lt;0.05) while glutamate levels were not. Taurine levels in both C and NC groups demonstrated a significantly decreasing trend over time, but the C group showed more reduction ( p &lt;0.05), while glutamate levels showed no significant trend. In mice, compared to saline, taurine treatment markedly improved 4h survival and MAP post-ROSC. Conclusions: Decreased release of taurine into blood is correlated with CA survival and may regulate CA outcomes. It has high translational potential as a biomarker for predicting CA survival, guiding cooling treatment, and serving as a therapeutic target to improve CA outcomes.

Abstract 204: Optic Nerve Sheath Diameter Trajectories During Targeted Temperature Management

Introduction: The extent of hypoxic-ischemic injury (HII) after cardiac arrest (CA) remains an important knowledge deficit with lack of objective clinical data that is measurable repeatedly. There is a need to better understand an individual patient’s level of HII. Optic nerve sheath diameter (ONSD) has not been explored after CA as a possible bedside modality to measure the extent of HII over time, at the bedside, during targeted temperature management (TTM). Objective: We sought to characterize the temporal trajectories of point-of-care ultrasound obtained ONSD during the post- return of spontaneous circulation (ROSC) phase, in patients with and without TTM. Methods: Adult CA patients at an urban academic ED were included from 2017-2021. ONSD was measured by emergency ultrasound fellowship trained faculty at 1, 6, 24, 48, and 72 hours after ROSC using an ocular preset on a 15MHz linear probe. ONSD measurements at these time points were compared with patient demographic information and intervention of TTM . Results: A total of 78 participants had ONSD measurements. The mean age was 62 (+/-15) and 46% were female. Of the 65% of the cases with TTM, a sex disparity was noted with 73% of males receiving TTM versus 56% of females. There was a trend toward a decrease in mean ONSD by 0.015cm for TTM patients during the early time points of 1 to 6 hours compared to an increase in 0.006cm in those without TTM. Similar trend was noted between 1 to 24 hours, with a decrease in ONSD by 0.025cm in those with TTM relative to an average increase of 0.008 cm in those without TTM. However, neither delta ONSD was statistically significant between the two cohorts. When further assessing if delay in cooling had an impact on ONSD change, we found that the ONSD change between 24 to 48 hours was significantly increased in those in whom TTM was not initiated within 14 hours (beta=0.036; p=0.016). Conclusion: This pilot study revealed ONSD changes during TTM. There is potential for monitoring brain injury through ONSD trajectories to evaluate responders vs non-responders to TTM. Additional research is needed to evaluate ONSD changes during the rewarming time frame and may further distinguish patients with worse HII. Correlation to survival outcomes can be possible with a larger sample size.

306 A Rapid Head CT Scan Protocol for Elderly Stable Patients Improves Time to Intracranial Hemorrhage Diagnosis

Minor head trauma is common in elderly patients. Intracranial hemorrhage (ICH) may present initially with minimal findings. Rapid diagnosis allows for rapid intervention with potentially better outcomes. In early 2020, a new ED protocol for all stable acute minor head trauma patients was instituted across two urban ED with the same MD staff. Patients meeting criteria were evaluated briefly by an attending MD who was paged to triage, and if otherwise stable and appropriate, had an expedited head CT performed.

Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review

BackgroundEmergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital.MethodsThis is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits—measured as ambulatory-care sensitive conditions (ACSCs)—were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis.ResultsSix percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits.ConclusionsWe revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings’ public health implications.

Association of Cannabis Use and At-Risk Alcohol Use With Intimate Partner Violence in an Urban ED Sample

IntroductionUrban ED patients have elevated rates of substance use and intimate partner violence. The purpose of this study is to describe the risk profiles for intimate partner violence among urban ED patients who report at-risk alcohol use only, cannabis use only, or both types of substance use. MethodsCross-sectional survey data were collected from study participants (N = 1037; 53% female; ages 18-50) following informed consent. We measured participants’ past-year at-risk drinking (women/men who had 4+/5+ drinks in a day), cannabis use, psychosocial and demographic characteristics, and past-year physical intimate partner violence (assessed with the Revised Conflict Tactics Scale). We used bivariate analysis to assess whether rates of intimate partner violence perpetration and victimization differed by type of substance use behavior. Multivariate logistic regression models were estimated for each intimate partner violence outcome. All analyses were stratified by gender. ResultsRates of intimate partner violence differed significantly by type of substance use behavior and were highest among those who reported both at-risk drinking and cannabis use. Multivariate analysis showed that women who reported at-risk drinking only, cannabis use only, or both types of substance use had increased odds for intimate partner violence perpetration and victimization compared with women who reported neither type of substance use. Men’s at-risk drinking and cannabis use were not associated with elevated odds of intimate partner violence perpetration or victimization. DiscussionBrief screening of patients’ at-risk drinking and cannabis use behaviors may help identify those at greater risk for intimate partner violence and those in need of referral to treatment.

How to Identify Sexual Assault and Intimate Partner Violence in Your ED

Sexual assault (SA) and intimate partner violence (IPV) are disturbingly common, with 1 in 3 women experiencing this kind of violence in their lifetime1. These patients are being seen in our EDs every day – a CDC study of an urban ED waiting room found 50% of people there had either SA or IPV as […]

Cannabinoid hyperemesis syndrome: A 6-year audit of adult presentations to an urban district hospital.

ObjectiveTo describe the local experience of adult patients presenting with cannabinoid hyperemesis syndrome (CHS) to an urban ED in the outer northern suburbs of Melbourne.MethodsRetrospective chart review of adult patients presenting to the ED with a documented history of CHS or equivalent terminology from January 2015 to January 2021. Age, sex, cannabis use, clinical features, pathology results, imaging and symptomatic management were examined as well as outcomes regarding disposition, representation, morbidity and mortality.ResultsOne hundred and forty‐two adult presentations were included. Sixty‐seven were unique presentations and 29 were patients who represented during the study period. Most represented within 3 months (37.8%) and most represented at least twice. Males were overrepresented (68.7%). Patients were young (median age 31 years, interquartile range 23–35 years) and all had a history of regular cannabis use (usually daily). Cyclical nausea and/or vomiting was the most common clinical feature compared to others in previously reported diagnostic criteria. Patients typically had elevated white cell counts with associated neutrophilia (75.8%) and mild hypokalaemia (57.9%). Lipase was not elevated, and C‐reactive protein was typically less than 50 mmol/L (98.2%). Imaging was not commonly performed but largely normal. Treatment was supportive with anti‐emetic use, intravenous fluids and analgesia. There were no deaths or admissions to intensive care.ConclusionsCyclical nausea and vomiting was the most common feature observed in this cohort compared to other clinical features reported in prior studies. Serum lipase was normal and C‐reactive protein only mildly elevated. Prospective studies are required to further assess these findings.

The pieta.

December 1986, my first job after residency. The medical community in Southeast Florida was overwhelmed by an explosive and frightening AIDS epidemic. The first antiviral drug active against HIV, known as AZT, would not be released until the following year. In the 1980s, AIDS was a relentless killer. The average time from diagnosis to death was 8–10 months. Before antiretrovirals, those with advanced AIDS presented with wasting, PCP pneumonia (now known as Pneumocystis jirovecii) and, in some, the disfiguring purple tumors of Kaposi's sarcoma. That evening, I was in the middle of a busy shift when I first saw him, a young man with lumpy violaceous growths across his face. He was painfully thin, and his face was sharp with sunken eyes and temporal wasting. He was small and almost lost in the in the large chair. His vital signs were unstable, but he had refused an IV or a resuscitation room. “I want a closed door” he told the nurse. In those early days of my career, I was quick and blunt. “What do you need?” I said. “I have AIDS. I am near the end and I don't want to die alone,” he whispered. “You are not in a gown,” I observed. “Everyone has to be in a gown.” “I don't want to be in a gown.” “Well how can I examine you? Draw blood, take x-rays?” “I don't want any of that. I just can't be alone tonight.” I started to get angry. “This is an emergency department. If you don't want tests or treatment, why don't you go and be with your friends? Your family?” He looked at the floor. Years later I reflected that it was ironic (and more than a little sad) that someone who did not want to die alone came to a busy urban ED and got me. I felt slightly remorseful. After all, I would soon be going home for Christmas and he was sitting alone staring at the floor, fading. In those days, most people with AIDS were often shunned by friends and family. During the mid-1980’s, the public (and even some doctors) worried that HIV could be transmitted by casual contact. “OK,” I said gruffly. You can stay for now, but you have to be in a gown. Every patient in my ED has to be in a gown.” (Thirty-two years ago, I imagined I could control the chaos by my “rules”—hence, the gown.) Things got busy and for the next several hours, I forgot about the young man. Near the end of my shift, I went back to his room. We needed to make some decisions, either he gets admitted or he goes home. In those insensitive days, I did not always knock before entering a room. When I opened the door, I saw a scene that remains as clear to me now as if only days have passed, rather than decades. A large, roughly dressed older man sat cradling the young man lying across his lap. My insistent gown had become a shroud. The scene mirrored Michelangelo's Pieta, with the older man looking tenderly at the motionless body in his arms. The violet flame of his sarcoma was extinguished in death, and those same stigmata now sparkled with his father's tears. I quietly closed the door and left. I never spoke to the father, ashamed I had not shown more compassion to his son. I turned over my patients to the oncoming physician and went home. Thirty years later, growing grayer (and thankfully kinder), I still think of that tableau. Emergency medicine grinds down even the most optimistic of us. Between the assaults, shootings, child abuse, self-destructive behavior, and other daily cruelties, we struggle to remain hopeful. But sometimes, in a quiet room, we see examples of humanity that restore us. Then we go home and hug our loved ones just a little bit tighter, for just a little bit longer.

Development of a 2-step algorithm to identify emergency department patients for HIV pre-exposure prophylaxis.

Expanded access to HIV PrEP is a central pillar of the "Ending the HIV Epidemic" initiative. Identification of PrEP eligible individuals in EDs remains understudied. Our goal was to estimate the accuracy of the Denver HIV Risk Score (DHRS), a quantitative HIV risk tool, for determining PrEP eligibility, and to incorporate it into a novel screening algorithm to optimize sensitivity and specificity. We performed a prospective cross-sectional study in two urban EDs. Patients were eligible if ≥18years of age and without HIV. Research staff collected individual HIV risk, components of the DHRS, and PrEP eligibility per 2017 CDC guidelines. Accuracy estimates were calculated for the DHRS alone and the DHRS plus additional PrEP-specific questions. 1002 patients were enrolled with a median age of 39years; 54.8% were male, 29.5% Black/non-Hispanic, and 22.5% Hispanic. Overall, 119 (11.9%, 95% CI: 9.9%-14.0%) were PrEP eligible; 5% endorsed history of sex with a partner at higher risk for HIV or condomless sex with multiple partners, 4% an STI, and 2% sharing IDU equipment. A DHRS ≥25 had a sensitivity of 92.4% (95% CI: 86.1%-96.5%) and a specificity of 17.2% (95% CI: 14.8%-19.9%) for PrEP eligibility. A 2-step algorithm, "DHRS-PrEP", beginning with a DHRS ≥25, followed by a step with questions specific to IDU, STI, and sexual partners improved the specificity to 100% (95% CI: 99.6%-100%). Among a heterogeneous ED sample, a substantial proportion was identified as PrEP eligible, and a 2-step algorithm had high sensitivity and specificity for identifying PrEP-eligible patients.

1028. Performance and Patient Acceptability Evaluation of the Chembio DPP® HIV-Syphilis Assay in an Emergency Department

BackgroundEmergency departments (EDs) serve as sentinel settings for diagnosing sexually transmitted infections (STIs), including HIV and syphilis. We aimed to assess performance and patient acceptability of a point-of-care (POC) test, the Chembio Dual Path Platform (DPP®) HIV-Syphilis Assay, in an urban ED in Baltimore.Methods170 patients were enrolled via convenience sampling from Oct 2019 – March 2020 and Jan 2021 – June 2021. Patients eligible were < 70 yrs, men who have sex with men, pregnant without care, had STI concerns, or history of drug use. Subjects received standard of care (SOC) HIV and syphilis testing under institutional laboratory algorithms. Subjects were then tested with the finger-stick POC test and completed a survey, both before and after the POC test to assess subjects’ attitudes about the POC test.ResultsComparing the SOC and POC results, 165/170 (97.1%) were test concordant. 3 syphilis POC results were false negative, but reported successful treatment over 10 years prior to enrollment (treponemal antibody remains after treatment). 1 HIV result was false negative and 1 was false positive. Overall the sensitivity and specificity of the HIV POC test were 96.8% (95%CI: 83.3%, 99.9%) and 99.3% (95% CI: 96.1%, 100%), and for syphilis were 85.7% (95%Cl: 63.7%, 97.0%) or 100% (95%CI: 81.5%, 100%), if excluding 3 persons having been successfully treated, and 100% (95% CI: 97.6%, 100%) respectively.The pre-test survey found 67% and 77% of participants were comfortable with a finger-stick test and agreed the POC test result would be as good as the SOC test result, which increased to 96% and 86% in the post-test, respectively, (p< 0.05). At post-test, 86% reported they would feel confident to perform this test at home and 81% would use it at least once per year if it were available. 97% reported they were more likely to seek treatment if receiving a positive result during their ED visit and 91% reported it would reduce their stress/anxiety if receiving a negative test result in the ED.ConclusionOur findings demonstrated satisfactory performance and high patient acceptability of the Chembio DPP® HIV-Syphilis Assay. Given the test is FDA approved, implementation studies are needed to determine whether adoption of this POC test will benefit patients and be consistent with ED workflows.Disclosures Richard E. Rothman, PhD, MD, Chem bio (Grant/Research Support)

Fitz-Hugh-Curtis syndrome in adolescent and young adult females: Utility of a decision rule.

The diagnosis of Fitz-Hugh-Curtis syndrome (FHC) is often missed or delayed in patients with right upper quadrant pain (RUQ). To develop a decision rule that predicts FHC in females with RUQ pain based on a constellation of historical features, physical examination findings and laboratory results. We conducted a prospective study to test the utility of our FHC decision rule in sexually active females, aged 13-20years, with RUQ pain who were seen in an urban ED over 57months. The decision rule was based on 4 features: 1. Presence of pleuritic chest pain, 2. Tenderness over the anterior border of liver, 3. History of worsening pain on R lateral position and 4. An erythrocyte sedimentation rate>30mm/h. The rule was considered positive if all 4 features were present. FHC was diagnosed in patients with RUQ pain and a positive GEN-PROBE Aptima Combo Assay for either gonorrhea or chlamydia on urine or endocervical specimens. 130 patients were enrolled. 24 were excluded, leaving 106 (81.5%) for analysis. 34/106 (32%) had STI/FHC. There were no differences in mean age or sexual characteristics between those with and without STI/FHC. A positive FHC decision rule had a positive predictive value of 75% (95%CI: 46.8%-91.1%) based on 96 cases for whom all features were available for analysis. Our decision rule shows promise in allowing for the early identification of FHC in adolescent and young adult females. Additional study is needed to corroborate these findings and test its generalizability.

Knowledge of COVID-19 and Health Literacy among Patients Seeking Care in an Emergency Department

Background: As the US continues to experience increases of COVID-19 cases, there is an urgent need to identify ways to improve individuals’ knowledge of COVID-19 to achieve effective prevention and vaccination. The primary objective of the current study was to examine whether the knowledge of COVID-19 was associated with the general health literacy among patients in an emergency department. Methods: A sample of 252 adults was collected in an urban ED. Patients’ knowledge of COVID-19 was measured by the agreement to 10 statements. Health literacy was measured by the Brief Health Literacy Screen (BHLS). Participants were also asked about their primary source of COVID-19 information, sociodemographics, comorbidities and familiarity with the healthcare system at baseline. Bivariate and multivariate analyses were conducted. Results: The average COVID-19 knowledge score was 7.09 (range 0-10) and BHLS score, 11.09 (range 3-15). About 43% obtained the information primarily from TVs, radios, and newspapers and only 8% from scientific sources. The group with the primary source being social media had the lowest average COVID-19 knowledge score of 6.25. The BHLS and COVID-19 knowledge scores were positively correlated in both bivariate and multivariate analyses. Compared to primary source of information being social media, internet sites and searches (p=0.03) and families, relatives, and friends (p=0.02) were associated with higher COVID-19 knowledge scores, controlling for other factors. Education and income levels were statistically significant in both the bivariate and regressions. Conclusions: Patients with better general health literacy had better knowledge of COVID-19. To better prevent further increases in COVID-19 transmission and improve the rate of vaccination, individuals of low educational and income levels should be prioritized in community interventions. Regulations on and/or guard against misinformation presented on social media platforms should be included in any effective interventions to improve individuals’ knowledge of COVID-19.

Association of a geriatric emergency department program with healthcare outcomes among veterans.

We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N= 725) and a matched control group (n= 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p< 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p< 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p< 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p< 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n= 57.5%], p= 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p= 0.004) without increasing ED length of stay (5.4± 2.2 vs. 5.4± 2.6h, p= 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p= 0.25) in the GERI-VET group. A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.

Abstract 13824: Computerized Tomography vs Ultrasound Imaging for Detecting Hypoxic-Ischemic Brain Injury

Introduction: After an out-of-hospital cardiac arrest (OHCA), the resulting hypoxic-ischemic injury (HII) to the brain remains the main cause of mortality. Standardized approaches for measuring the extent of injury and monitoring of changes are lacking and continue to be a critical barrier to progress in improving neurological survival. Objective: We sought to characterize the prevalence of HII detected on computerized tomography of the brain and its correlation to point-of-care optic nerve sheath diameter (ONSD) measurements as an alternative modality for detecting brain injury. Methods: Adult OHCA patients at an urban academic ED were included in this study on a convenience sample basis from 2018-2019. The patients were grouped by findings of hypoxic-ischemic injury (HII) on both initial and subsequent CT brain imaging performed after ROSC in respective groups. CT Brain findings were compared to ONSD measurements as performed with point-of-care ultrasound by fellowship-trained emergency physicians within one hour of hospital arrival and at 6 hours, after return of spontaneous circulation (ROSC) and to cerebral performance category (CPC) at hospital discharge. Results: 76 patients enrolled in the study had a median age was 59, 49% were female, and 37% survived to hospital discharge. 58 patients had CT head performed, 40 had ONSD measured within one hour, and 27 patients had both. Of that 27, 9 (33%) had evidence of HII on initial imaging and 15 (55%) had evidence of HII on subsequent imaging for a total of 20 unique patients. The average ONSD within 1 hour of ROSC for those with no HII on any imaging was 0.59 cm, and for those without HII on initial imaging but with HII on subsequent imaging was 0.67 cm, and this difference was statistically significant (p&lt; 0.05). Of the 20 patients with HI, 14 (70%) patients died and 6 (30%) survived with a CPC of 4. The average time to first CT head was 4 hours and 45 mins and the average time to subsequent imaging was 97 hours and 45 mins. Conclusion: After an OHCA, early time point ONSD measurements can potentially indicate brain injury within 1 hour of ROSC even in those without initial evidence of HII on CT imaging.

123 Deep-Learning Generated B-Line Score Mirrors Clinical Progression of Disease for Patients Admitted With Shortness of Breath or Hypoxia

Thoracic ultrasound can evaluate the lungs for fluid in the alveolar and interstitial spaces of the lung, based on the presence of artifacts known as B-lines. Degree of B-lines may provide an independent measure of severity of pulmonary edema in congestive heart failure. Artificial intelligence can be used to provide objective data, improve interpretations by novice users, and allow processing of large amount of data for research. The aim of this study is to determine the association between a B-line score using a deep learning algorithm with the degree of pulmonary congestion based on clinical assessment and its variation with response to treatment. This single-center, prospective, observational study enrolled adult patients presenting with dyspnea or hypoxia and suspected to have congestive heart failure at an urban academic ED from July 2018 to May 2019. Subjects found to have any B-lines on initial lung ultrasound were followed through their hospital course and included in this analysis. Admitted patients underwent daily ultrasonography. Clips of 8 lung zones (right and left anterior/lateral and superior/inferior) were obtained using the Philips LumifyTM ultrasound system with sector probe. Demographics, vital signs, lab values, and imaging results were also collected. A previously published deep learning algorithm was refined to rate the severity of B-lines on a scale of 0-4 in 0.5 increments. Average severity for all 8 zones at each time-point for each patient was calculated. A clinical congestion score (0-18 scale), based on presence of dyspnea, orthopnea, fatigue, JVD, rales and pedal edema was calculated. Mixed effects modeling was used to investigate the association between B-line score as independent variable and clinical congestion score as dependent variable, accounting for variation on the person level and longitudinal data. Missing data was excluded from analysis. Covariates tested included patient and exam level data (sex, age, presence of selected comorbidities, baseline sodium and hemoglobin, creatinine, vital signs, oxygen delivery amount and delivery method, diuretic dose). There were 242 unique subjects with 722 complete sets of 8-zone clips included in the analysis. For the mixed effects model, chosen covariates were: sex, baseline sodium, baseline hemoglobin, respiratory rate, CHF, chronic obstructive pulmonary disease, fraction of inspired oxygen, oxygen delivery method (eg, nasal cannula, non-rebreather, ventilator), total loop diuretic dose on day of exam, and the 8-zone DL obtained B-line score. There was no collinearity. The 8-zone B-line score was significantly associated with clinical congestions core, with coefficient of 0.73 (p<0.001). A deep learning generated B-line score mirrors clinical course for subjects admitted patients with shortness of breath or hypoxia, independent of other patient and clinical factors. B-line quantification using AI can provide an objective and independent measure of pulmonary congestion in patients with congestive heart failure and can be used to help monitor clinical progress.

367 Rural Rates of Hepatitis C Within an Emergency Department-Based Universal Screening Program

As a consequence of the opioid epidemic, overall Hepatitis C (HCV) infections have increased in the United States. HCV mortality now surpasses more than 60 other infections (eg, HIV, and TB). The CDC now recommends universal HCV screening, for all adults aged ≥18 years. Several reports highlight the success of large urban EDs to provide screening and linkage to care for HCV but the ability to utilize rural EDs has not been explored. Our objective was to highlight results of an electronic health record (EHR) driven “opt-out,” universal HCV screening program in a small rural community ED that serves the economically disadvantaged, rural/mountainous area of SC, including parts of Appalachia.