Urban ED Research Articles

Temporal trends in emergency department volumes and crowding metrics in a western Canadian province: a population-based, administrative data study

BackgroundEmergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs. The study quantifies and compares crowding metrics for 16 high volume regional, urban and academic EDs in one Canadian province.MethodsThe National Ambulatory Care Reporting System (NACRS) provided ED presentations by adults to 16 high volume Alberta EDs during April 2010 to March 2015 for this retrospective cohort study. Time to physician initial assessment (PIA), length of stay (LOS) for discharges and admissions were grouped by start hour of presentation and facility. Multiple crowding metrics were created by taking the means, medians (PIA-M, LOS-M), and 90th percentiles of the hourly, ED-specific values. Similarly, proportion left against medical advice (LAMA) and proportion left without being seen (LWBS) were day and ED aggregated. Calculated based on the start of the presentation and the facility and for PIA and LOS. The mean, median, and 90th percentiles for the date and time ED-specific metrics for PIA and LOS were obtained. Summary statistics were used to describe crowding metrics.ResultsThere were 3,925,457 presentations by 1,420,679 adults. The number of presentations was similar for each sex and the mean age was 46 years. Generally, the three categories of EDs had similar characteristics; however, urban and academic/teaching EDs had more urgent triage scores and a higher percentage of admissions than regional EDs. The median of the PIA-M metric was 1 h23m across all EDs. For discharges, the median of the LOS-M metric was 3h21m whereas the median of the LOS-M metric for admissions was 10h08m. Generally, regional EDs had shorter times than urban and academic/teaching EDs. The median daily LWBS was 3.4% and the median daily LAMA was about 1%.ConclusionsEmergency presentations have increased over time, and crowding metrics vary considerably among EDs and over the time of day. Academic/teaching EDs generally have higher crowding metrics than other EDs and urgent action is required to mitigate the well-known consequences of ED crowding.

Dedicated emergency department physical therapy is associated with reduced imaging, opioid administration, and length of stay: A prospective observational study.

BackgroundEmergency department based Physical Therapy (ED-PT) has been practiced globally in various forms for over 20 years and is an emerging resource in the US. While there is a growing body of evidence suggesting that ED-PT has a positive effect on a number of clinical and operational outcomes in patients presenting with musculoskeletal (MSK) pain, there are few published narratives that quantify this in the US. Although there are international papers that offer outcome data on reduction of pain, imaging, throughput time, and the ability of physical therapists to appropriately manage MSK conditions in the ED setting, most papers to date have been descriptive in nature. The purpose of this study is to assess the impact of ED-PT on imaging studies obtained, rates of opioids prescribed, and ED length of stay.MethodsWe prospectively identified patients presenting with musculoskeletal pain to an urban academic ED in Salt Lake City between January 2017 and June 2018. During the study, a physical therapist was in the ED three days (24 hours) per week and was available to evaluate and treat patients after consultation by the ED provider. We noted patient demographic information, imaging performed in the ED, medications administered and prescribed, and ED length of stay. We classified patients as those who received PT in the ED and those who did not and compared clinical outcomes between groups. We performed a subgroup analysis of patients presenting with low back pain and matched patients by age and gender.ResultsOver the 18-month study period, we identified 524 patients presenting to the ED with musculoskeletal pain. 381 (72.7%) received ED-initiated PT. The PT and non-PT groups were similar in average age (42.8 years vs. 45.1 years, p = 0.155), gender (% female: 53% vs. 46.9%, p-0.209), and primary presenting chief complaint (cervical, thoracic, or lumbar pain: 57.7% vs. 53.1%, p = 0.345). Patients who received PT had lower rates of imaging (38.3% vs. 51%, p = 0.009), ED opioid administration (17.5% vs. 32.9%, p<0.001), and a shorter average ED length of stay (4 hours vs. 6.2 hours, p<0.001). Rates of outpatient opioid prescriptions were similar between groups (16% vs. 21.7%, p = 0.129). In a subgroup analysis of patients presenting with low back pain, we found that PT patients had fewer imaging studies (PT 25% vs. non-PT 57%, p = 0.029) but found no difference in average ED length of stay (PT 3.7 hours vs. non-PT 4.6 hours, p = 0.21), opioid administration in the ED (PT 36% vs. non-PT 43%, P = 0.792), nor outpatient opioid administration (PT 17.9%. vs non-PT 17.9%, p = 1.0).ConclusionIn our experience, being seen by a physical therapist for MSK pain within the ED was associated with reduced use of imaging and time spent in the ED. Patients seeing a Physical Therapist were also less likely to receive an opioid prescription within the ED, a potentially significant finding given the need for opioid reduction strategies.

Are expiratory radiographs more sensitive than inspiratory radiographs for the diagnosis of pneumothorax in the emergency department? A retrospective observational study.

Expiratory radiographs are sometimes performed in addition to inspiratory radiographs when a diagnosis of pneumothorax is suspected. There is little published evidence to support this practice and most studies suggest the additional radiograph does not confer any benefit in terms of increased sensitivity. The present study is the first to assess if specialist emergency physicians are more likely to detect a pneumothorax on an inspiratory radiograph compared to an expiratory radiograph. Across two urban district EDs 103 paired radiographs positive for pneumothorax and 112 negative controls were identified for inclusion in the study. These were reviewed by three specialist emergency physicians who rated them as either positive or negative for pneumothorax. The mean sensitivity for the three reviewers was 84.8% (95% CI 82.0-87.5) for the inspiratory radiographs and 91.9% (95% CI 88.2-95.6) for the expiratory radiographs, a mean absolute difference of 7.1% (95% CI 2.2-12.1, P = 0.025) in favour of expiratory radiographs. When reviewed by emergency physicians the present study found expiratory radiographs confer an increase in sensitivity for the diagnosis of pneumothorax compared with inspiratory radiographs. In certain patients where the clinical suspicion for pneumothorax is high performing an expiratory radiograph may increase the likelihood of the diagnosis being made in the ED.

Parent-Centered Perspectives on a Validated Asthma Questionnaire in the Emergency Department

ObjectiveAlthough national asthma guidelines recommend use of validated questionnaires to improve asthma care, little is known about the extent to which these questionnaires are patient-centered. This qualitative study evaluated parent perceptions of a validated asthma questionnaire. MethodsWe administered the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) to parents of children 2 to 17 years old presenting to a large urban pediatric ED for asthma care and assessed their perceptions of the tool's utility and acceptability via a structured interview. Responses were recorded, transcribed, and analyzed using a phenomenological approach. ResultsEighty-three parents participated. Qualitative analysis revealed 2 major themes (with 5 subthemes). The first major theme (and 3 subthemes) was that the PACCI-ED facilitated communication with the health care team and caregivers: improving communication 1) with ED providers, 2) in other settings such as schools, and 3) in the primary care setting where the relationship with primary care providers was felt to be variable. The second major theme (and 2 subthemes) was that the PACCI-ED increased parents’ capacity to manage their child's asthma: by helping parents understand 1) what symptoms were related to asthma and 2) how those symptoms might change over time. ConclusionsParents perceive that the PACCI-ED is acceptable and useful for facilitating communication in the ED and other health care settings, and for building parent capacity to track and manage their child's asthma. A validated structured asthma questionnaire in the ED may facilitate patient-centered asthma care.

Intubation in acute alcohol intoxications at the emergency department

BackgroundGuidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury.MethodsWe performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations’ characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury.ResultsOf 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0–2.2] vs. 1.6 g/kg [IQR1.1–2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011).ConclusionsIntubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study - without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.

Using geographic information systems to map older people’s emergency department attendance for future health planning

ObjectivesThis study aimed to assess the pattern of use of EDs, factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or older to a large...

Abstract 334: Point-Of-Care Ultrasound in the Assessment of Optic Nerve Sheath Diameter After Out-Of-Hospital Cardiac Arrest

Introduction: Hypoxic-ischemic injury from cardiac arrest may cause cerebral edema, leading to increased intracranial pressure (ICP) and brain tissue damage. Optic nerve sheath diameter (ONSD) is associated with elevated ICP. Limited clinical studies have reported ONSD changes in the early post-resuscitation time frame. We sought to evaluate the utility of bedside ocular ultrasound measurements in the assessment of post-cardiac arrest brain injury. Methods: We studied adult out-of-hospital cardiac arrests treated at an urban academic ED and achieving return of spontaneous circulation (ROSC) between May 2018 to May 2019. We included witnessed and unwitnessed arrest as well as shockable and non-shockable rhythms. After ROSC, trained emergency physicians performed bedside ultrasonographic assessment of bilateral ONSD at 1, 6, 24, 48, and 72 hours using an ocular preset on a 15MHz linear probe. ONSD measurements at these time frames were compared between groups stratified by rhythm type and neurological outcome. Cerebral performance category (CPC) was measured at 72 hours and at discharge. Results: Out of 48 eligible patients, 15 were excluded from the study due to lack of consent or available ultrasound images. We included 33 patients, of which 11 were female and 22 were male, with a median age of 57 (IQR 20). There were 19 with an initial rhythm of asystole or pulseless electrical activity (PEA), 9 with ventricular fibrillation arrests, and 5 with an unclear rhythm. At 1 hour, patients with CPC 1-2 had smaller ONSD compared to patients with CPC 3-5 (5.5mm vs 6.1mm, p=0.03). At 72 hour, patients with CPC score of 1-2 had an average reduction in ONSD of 1.6mm verses 0.29mm increase in patients with CPC 3-5. Despite small sample size, a trend towards higher ONSD were seen in patients with non-shockable vs shockable rhythm. Females were also consistently found to have smaller ONSD measurements in all time periods compared to males. Conclusions: This is the first study in the USA to perform analysis using ONSD measurements in cardiac arrest patients. Preliminary analysis of this on-going pilot revealed a greater improvement in ONSD diameters in patients with a favorable neurological outcome. OSND may have utility in prognostication of the post-arrest state.

Focused Teaching Improves Medical Student Professionalism and Data Gathering Skills in the Emergency Department.

Introduction: Leaders in medical education have developed milestones and core competencies in an attempt to ensure that relational skills, such as communication and professionalism, are emphasized in addition to the usual skills of medical knowledge, data gathering, and emergency stabilization during students' emergency medicine (EM) medical education. Providers facile in each of these areas have better patient outcomes, patient experiences, and decreased incidence of malpractice cases. The authors attempted to demonstrate that by deliberate teaching of these skills during an EM medical student clerkship, students could significantly improve their clinical performance.Methods: This prospective, randomized, single-blinded cohort study was performed at an academic, tertiary, urban ED to investigate the effects of a one-on-one preceptor shift on the clinical performance of fourth-year medical students. Students were randomized into two groups and assessed by pre- and post-intervention objective structured clinical encounters (OSCEs) with standardized patients (SPs) at weeks one and three. A crossover design was employed so that students in the control group participated in a preceptor shift after their second OSCE. Measurements were based on a five-point Likert scale assessment linked to early EM milestones as defined by the Accreditation Council on Graduate Medical Education (ACGME). Results: The mean improvement in total overall score was significantly greater in the intervention group: 4.31 versus 2.57 (Cohen’s d = 0.57, p = 0.029). When each milestone was assessed individually, students in the intervention group improved significantly in data gathering (Cohen’s d = 0.47, p = 0.048) and professionalism (Cohen’s d = 0.66, p = 0.011). There was a nonstatistically significant improvement for the intervention compared to control group in emergency management and communication skills. There was no improvement for either group in medical knowledge.Conclusion: A one-on-one preceptor shift can result in a statistically significant improvement in data gathering and professionalism skills as measured by OSCEs.

Advancing telestroke interventions in an urban ED.

Advancing telestroke interventions in an urban ED.

The influence of race and sex on gonorrhea and chlamydia treatment in the emergency department

BackgroundEmergency Departments (EDs) are a care source for patients with sexually transmitted diseases (STDs). St. Louis, MO reports among the highest rates of gonorrhea and chlamydia infection. We examined STD treatment in a high-volume urban ED, in St. Louis MO, to identify factors that may influence treatment. MethodsA retrospective chart review and analysis was conducted on visits to a high volume, academic ED in St. Louis, MO where patients received a gonorrhea/chlamydia nucleic acid amplification test (NAAT) with a valid matching test result over two years. Using multiple logistic regression, we examined available predictors for under and overtreatment. ResultsNAATs were performed on 3.3% of all ED patients during the study period. Overall prevalence was 6.9% for gonorrhea (95% CI: 6.2, 7.7) and 11.6% for chlamydia (95% CI: 10.6, 12.5). Race was not a statistically significant predictor for undertreatment but Black patients were significantly more likely to be overtreated compared to White patients. (OR 1.83, 95% CI: 1.5, 2.2). Females were more likely to be undertreated when positive for infection compared to males (OR 7.34, 95% CI: 4.8, 11.2) and less likely to be overtreated when negative for infection (OR 0.27, 95% CI: 0.2, 0.3). ConclusionThe burden of STDs in a high-volume academic ED was significant and treatment varied across groups. Attention should be paid to particular groups, specifically women and patients reporting Black as their race, to ensure appropriate treatment is administered. Patients would benefit from targeted STD management protocols and training in the ED.

P100: A needs assessment to guide the development of multidisciplinary simulation-based modules relevant to emergency department nurses in Newfoundland and Labrador

Introduction: Efficient multidisciplinary team dynamics are crucial to the provision of optimal ED care. Physicians and nurses must use a collaborative approach to meet patient needs in this busy setting. This is especially important for high-acuity low-occurrence (HALO) procedures and clinical encounters. Simulation provides a safe environment where learning is enhanced through deliberate practice. Multidisciplinary participation in simulation-based education may augment team cohesiveness and performance. Methods: A web-based needs assessment survey was distributed to ED nurses, collecting information on demographics, opinions about simulation-based instruction and perceptions on the value of the proposed collaborative educational approach of the project. Experience and comfort with nursing roles in specific procedures (TV pacer, surgical airway, chest tube, central line, sedation) and clinical encounters (STEMI, CVA, sepsis, anaphylaxis, GI bleed) seen in the ED were also assessed. There were a number of suggestions for topics in addition to those listed. Responses will guide the collaborative development of simulation modules with nursing colleagues on desired topics. Results: 58/97 potential nurse participants from 2 urban ED's responded to the survey over an 8-week period, giving a response rate of 58.8%. 76% of respondents had less than 10 years of ED nursing experience, and 34.48% less than 5 years. Responses indicate limited familiarity with simulation-based education (SBE) on ED scenarios with 33.93% being not familiar; 55.36% somewhat familiar. Most prior simulation experience was with role-playing (82%) or low-fidelity setups (42%). Perceived benefit of SBE sessions was substantial (43.86%- very significant; 45.61%- significant). Most respondents had limited past exposure (22.81%- none; 64.91%- 1-5 sims). Similarly, there was little ongoing participation in SBE events with none in 43.64% and 40% just annually. For the 5 clinical scenarios, average responses were: Comfort with assisting 87.45%; Interest in further training 91.43%; Willingness to participate 94.13%. For the 5 procedures, averages were 36.35% (21.36% excluding sedation), 91.27%, 89.09%, respectively. Conclusion: Results indicate a low level of familiarity, experience and ongoing exposure with SBE relating to ED training and practice. Participants recognize the potential benefits of using simulation in a multidisciplinary educational setting and indicate a willingness to participate in collaborative teaching sessions.

P081: Distribution of take home naloxone in Edmonton zone emergency departments between January 2016 and December 2017

Introduction: Morbidity and mortality from opioid overdoses continue to be a significant issue worldwide. In Alberta, there was a 40% increase in accidental opioid-related deaths from 2016 to 2017. In response to this crisis, Alberta Health Services has dramatically expanded access to Naloxone with a province-wide program for the distribution of take-home naloxone (THN) kits. Edmonton Zone ED's began dispensing these kits in 2016. The objectives of this study are to assess the trends in THN kit distribution from these sites in 2016 and 2017. Methods: The Edmonton Zone is a health region that comprises eleven tertiary, urban community and rural community ED's. THN kits in Edmonton Zone ED's were distributed through Pyxis, an automated medication dispensing and tracking system. Pyxis data for THN kits in 2016 and 2017 was extracted for each Edmonton Zone ED and the raw numbers and trends were examined. The National Ambulatory Care Reporting System database was also analyzed to determine the number of opioid related visits to Edmonton Zone ED's over that same time period. Results: A total of 686 THN kits in the Edmonton Zone were distributed over 2016 and 2017. The two tertiary centers distributed 502 kits, while the urban and rural community emergency departments collectively distributed 184 kits. Comparing 2016 (n = 245) to 2017 (n = 441), there was an 80% overall increase in the number of kits distributed, with tertiary center ED's dispensing 92% more kits, urban community ED's 51% more and rural ED's 63% more. Over the same time period, the number of opioid related visits increased in tertiary center ED's by 78%, in urban community sites by 26%, and in rural ED's by 67%. Almost all ED's increased their THN kit distribution from year to year, though there was one urban community site that dispensed fewer kits in the second year of the program. Conclusion: Edmonton Zone ED's dispensed 686 THN kits over two calendar years. Almost every ED distributed more kits in 2017 than 2016, which likely reflects successful uptake of this harm reduction intervention by frontline ED staff. However, there is still evidence of some imbalance in THN kit allocation as the percent increase in kits distributed varied widely based on the type of ED. This data can be used to pinpoint areas in the Edmonton Zone where barriers to THN access may still exist and guide continued quality improvement interventions to increase distribution and education.

P005: An opportunity to reduce morbidity in delayed postpartum hemorrhage: Multicentre analysis of tranexamic utilization in the emergency department

Introduction: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to be efficacious and safe in reducing mortality and morbidity if given within 3 hours of bleeding onset. Delayed PPH of more than 24 hours after delivery is a rare but high-risk ED presentation that requires timely management with TXA. This study aims to evaluate the patterns of TXA administration to treat delayed PPH in the ED using a retrospective review of medical reviews from 4 centres across a major urban Canadian city. Methods: We conducted a retrospective medical record review of patients presenting with PPH to 4 large urban EDs from 2013 to 2017; from 1.5 million ED visits, using a search for ICD-10 diagnostic codes of interest. Of these, the study cohort included only patients that were admitted to the hospital. Univariate analyses using Chi-squared tests and t-tests for non-continuous and continuous variables, respectively, were used to determine patient demographics and clinical characteristics significantly associated with TXA administration. Results: A total of 238 patients were included in the study cohort. Of these patients, 72.7% presented to the ED with mild hypovolemic shock, defined by a shock index score greater than 0.6. A total of 12.6% (95% CI 0.09-0.17) of patients were given TXA for PPH management in the ED. 67% (95% CI 0.47-0.82) of patients received the TXA within 3 hours of triage, whereas 33% (95% CI 0.18-0.53) received it after 3 hours, with the total mean time at 3.43 hours. 4.2% of patients required a blood transfusion and 2.9% required surgery. Univariate analyses indicated that greater maternal age (p = 0.028), lower hemoglobin levels (p = 0.014), higher shock index scores (p = 0.001), greater heart rate (p = &amp;lt; 0.001)), and use of oxytocin (p = &amp;lt;0.001) or blood products (p = &amp;lt; 0.001) in the ED were all significantly associated with TXA administration. Conclusion: The results from this study demonstrate that only 13% of delayed PPH patients presenting to the ED received TXA, and among those treated, 66% received TXA within 3 hours of presentation. The use of TXA was correlated with variables associated with an increased risk of morbidity. Given the rarity of delayed PPH presentation to the ED, the development of a treatment algorithm is recommended to ensure higher levels of timely TXA administration.

Distinct subgroups of emergency department frequent users: A latent class analysis

BackgroundEmergency department (ED) frequent users have high resource utilization and associated costs. Many interventions have been designed to reduce utilization, but few have proved effective. This may be because this group is more heterogeneous than initially assumed, limiting the effectiveness of targeted interventions. The purpose of this study was to identify and describe distinct subgroups of ED frequent users and to estimate costs to provide hospital-based care to each group. MethodsLatent class analysis was used to identify homogeneous subgroups of ED frequent users. ED frequent users (n = 5731) from a single urban tertiary hospital-based ED and level 1 trauma center in 2014 were included. Descriptive statistics (counts and percentages) are described to characterize subgroups. A cost analysis was performed to examine differences in direct medical costs between subgroups from the healthcare provider perspective. ResultsFour subgroups were identified and characterized: Short-term ED Frequent Users, Heart-related ED Frequent Users, Long-term ED Frequent Users, and Minor Care ED Frequent Users. The Heart-related group had the largest per person costs and the Long-term group had the largest total group costs. ConclusionDistinct subgroups of ED frequent users were identified and described using a statistically objective method. This taxonomy of ED frequent users allows healthcare organizations to tailor interventions to specific subgroups of ED frequent users who can be targeted with tailored interventions. Cost data suggest intervention for long-term ED frequent users offers the greatest cost-avoidance benefit from a hospital perspective.

(366) Opioid Prescription Practices in the Setting of Pediatric Fractures

Opioids are frequently prescribed to children with fractures. Although much research has been done surrounding the use of opioids in adult populations, use of opioids among children is much less understood. The purpose of this study was to investigate pediatric opioid prescription trends over the last ten years, and to compare prescription practices between doctors of different specialties. We performed a retrospective analysis of all patients age 0-18 who presented to an urban ED between 2007-2017 for fracture care. Data collected included age, opioids given in the ED, opioid prescriptions from the ED, follow-up appointment specialty, and opioid prescriptions from the first follow-up visit. Opioid prescription quantities were assessed in morphine equivalents (MEs). From pilot data of 1,387 patients with fractures, 488 patients (35.2%) received an opioid medication in the ED. Morphine (202, 14.6%) and oxycodone (191, 13.7%) were the most common opioids give in the ED setting though oral hydrocodone and codeine, and IV fentanyl and hydrocodone were also used. Opioid prescriptions from the ED were given to 491 patients (35.4%), with a mean quantity of 111.7 MEs (SD=74.4). 1,059 patients attended a follow-up appointment. 47 of the 844 (6.7%) patients who followed-up with orthopedics, and 14 of the 103 (13.5%) who followed up with plastics received opioid prescriptions. The mean quantity of opioid prescribed at the first follow-up visit was 256.1 MEs (SD=162.9). Preliminary data suggests that larger quantities of opioids are given at follow-up visits than are given in the ED. For pediatric fractures, plastic surgeons prescribe opioids twice as frequently as orthopedic surgeons. The next step for this research to draw comparisons between patients of different age groups and different fracture types.

Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients

BackgroundCrowding is a major challenge faced by EDs and is associated with poor outcomes.ObjectivesDetermine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations.MethodsWe conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts.ResultsDisposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]).ConclusionED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis.

The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission. We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7- and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests. We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p<0.001), PE (18% from 12%, p=0.002), low-risk PE (28% from 18%, p<0.001), and DVT (60% from 49%, p=0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol. A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.

Impact of Targeted Temperature Management on ED Patients with Drug Overdose-Related Cardiac Arrest.

Drug overdose is the leading cause of non-traumatic out-of-hospital cardiac arrest (OHCA) among young adults. This study investigates whether targeted temperature management (TTM) improves hospital survival from presumed overdose-related cardiac arrest. Retrospective chart review of consecutive cardiac arrests presenting to an urban tertiary care hospital ED from 2011 to 2015. ED patients with cardiac arrest were included if < 50years old, and excluded if there was a non-overdose etiology (e.g., trauma, ST-elevation myocardial infarction, subarachnoid hemorrhage). The main intervention was TTM, carried out with a combination of the Arctic Sun device and refrigerated crystalloid/antipyretics (goal temperature 33-36°C). The primary outcome was survival to hospital discharge; neurologically intact survival was the secondary outcome. Of 923 patients with cardiac arrest, 802 (86.9%) met exclusion criteria, leaving 121 patients for final analysis. There were 29 patients in the TTM group (24.0%) vs 92 patients in the non-TTM group (76.0%). Eleven patients (9.1%) survived to hospital discharge. TTM was associated with increased odds of survival to hospital discharge (OR 11.3, 95% CI 2.8-46.3, p < 0.001), which increased substantially when palliative outcomes were excluded from the cohort (OR 117.3, 95% CI 17.0-808.4, p < 0.001). Despite achieving statistical significance (OR 1.1, 95% CI 1.0-1.3), TTM had no clinically significant effect on neurologically intact survival. TTM was associated with improved survival in ED patients with presumed drug overdose-related cardiac arrest. The impact of TTM on neurologically intact survival among these patients requires further study.

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care

ObjectivePhysical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting. MethodsThis was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression. Results74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48–2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50–8.83). ConclusionsIn this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.

63 The Impact of a Concierge Medicine Model in the Emergency Department on Diagnostic Test Utilization

Study Objectives: The use of a concierge physician model has been employed in the emergency department setting to decrease the door-to-physician time, but this method has been found to concurrently increase the overall ED dwell time by delaying the time needed for medical decisionmaking. The purpose of this study was to identify methodology that could measure the impact of physician testing on patient flow and diagnostic test utilization. We performed a retrospective observational cohort study in an urban academic ED. All available records with adult visits during a 1-month period were reviewed. Patients were analyzed by cohort based on whether or not they were initially seen by a concierge physician prior to formal ED evaluation. The theoretical model identified index tests within categories of physician orders rather than an absolute test count. A complete blood count represented blood work, a chest radiograph represented radiographic imaging, Computed axial tomography (CT) and ultrasound were analyzed independently in the most common body regions. Head and abdomen for CT and abdominal and pelvic for ultrasound. The purpose of this analysis was to give equal weight to testing modalities but not over weight for related tests. The unit cost in our analysis was time and not money, so a complete blood count with a basic metabolic panel and cardiac biomarkers did not significantly add additional time to a patient’s ED stay and were only counted as one test in our index analysis. During the study period, the ED evaluated 9,836 adult patients. Of those, 2,609 (26%) were seen initially by a concierge physician (CP). Patients evaluated by a CP were 1.75 times more likely to have an index test of any sort ordered on them. The probability of at least one order was 0.78 for the CP cohort and .45 for the non-CP cohort. Patients had a mean number of index tests ordered of 1.44 in the CP cohort and 0.78 when not seen initially by a CP physician (95% CI for difference 0.61, 0.70) Using an index test analysis yielded a streamlined evaluation of testing patterns that emerged as a result of a concierge medicine model. This model was more clinically relevant than an absolute test count and easier to implement in ongoing tracking. The index test method would also tend to underestimate the true count of testing (such as extremity radiographs). Placing an administrative emphasis on door-to-physician time had the unintended consequence of nearly doubling the amount of diagnostic testing ordered on patients presenting to an urban ED.