Urban Emergency Department Research Articles

Documentation of incidentally noted hepatic steatosis to emergency department patients: A retrospective study.

Hepatic steatosis is a common incidental finding on emergency department (ED) imaging studies, occurring in up to 10% of studies, and carries significant long-term morbidity. Frequently considered an unimportant finding, it is unknown how often ED patients are informed of hepatic steatosis. Our objective was to examine hepatic steatosis inclusion in ED discharge materials. Data from discharged patients at an urban academic ED (>90,000 visits) with abdominal imaging (computed tomography or ultrasound) from 2019 to 2022 were screened. Patients with radiology reports documenting hepatic steatosis were included. Two trained data abstractors analyzed discharge materials and coded disclosure of steatosis (present/absent). Data abstraction also noted how the finding was included (e.g., follow-up instructions, provision of radiology report). Factors associated with patient disclosure were examined through regression models including age, race, ethnicity, insurance, number of imaging studies during encounter, type of imaging study, and inclusion of hepatic steatosis in the impression section of radiology report. Of 10,677 radiology reports, 1209 (11.3%) had documented hepatic steatosis. The mean (±SD) age was 47.1 (±14.1) years; 56.4% were female, 53.5% were White, and 30.7% Hispanic. Only 173 of 1209 patients (14.3%) received any discharge documentation of hepatic steatosis. In 65% of cases where disclosure occurred, the imaging report was pasted verbatim into discharge material. There were no significant differences in discharge documentation by demographic groups. Mention within the radiology report impression (rather than the report body alone) occurred in 73.8% of records and was the strongest predictor of disclosure to patients (adjusted odds ratio 2.18, 95% confidence interval 1.39-3.54). Despite the high prevalence of hepatic steatosis in radiology reports, rates of documentation in patient-facing discharge materials are notably low, exposing a possible communication failure with consequences for diagnosis.

The Impact of COVID-19 on Patterns of Fractures Presenting to Pediatric Emergency Departments.

To examine differences in pediatric fracture prevalence, severity, and mechanisms of injury before and during the COVID-19 pandemic. This is a subanalysis of data from a multicenter, cross-sectional study of all injury-related visits to 40 urban pediatric emergency departments (EDs) for children younger than 18 years occurring January 2019-December 2020. ED visits for injuries including fractures were identified by International Classification of Diseases, Tenth Revision codes. Comparative analyses of patient demographics, fracture prevalence, severity, and mechanisms of injury for March 17, 2019, to December 31, 2019 (pre-COVID), versus March 15, 2020, to December 31, 2020 (during COVID), were performed. Fracture-related visits comprised 21.0% (n = 123,684) of all injury visits (n = 589,083) during the study period. There were 16,190 fewer fracture-related visits (-23.2%) in 2020 than 2019. There were differences in the proportion of fracture-related visits by age (P < 0.0001), with increases in children younger than 5 years and decreases in children 5 to 18 years old. There were higher proportions of visits in 2020 among female patients, White children, non-Hispanic children, and those with private insurance (P < 0.0001, respectively). Patients with fractures in 2020 were more severely injured, with higher proportions of hospitalizations (P < 0.0001), intensive care unit admissions (P < 0.0001), deaths (P = 0.007), and higher injury severity scores (P < 0.0001). Fracture mechanisms shifted to more motor vehicle crashes, bicycles, and firearms in 2020 (P < 0.0001). Despite a decrease in fracture-related visits to urban pediatric EDs during the early COVID-19 pandemic, there was an increase in the proportion of ED visits for children younger than 5 years and higher severity injuries. These findings highlight injury epidemiology pattern shifts that occurred during the pandemic. Identifying higher-risk populations for fracture may help guide targeted education and prevention efforts.

Workplace Violence in a Large Urban Emergency Department

Workplace violence (WPV) against health care workers (HCWs) is common and likely underreported. Reliable data on the incidence of WPV and its impact on victims are lacking. To prospectively define the frequency of WPV against HCWs in the emergency department (ED), examine whether HCW demographics are associated with increased risk, and explore the impact of these events on HCWs. This cross-sectional study was conducted over 2 months in 2023 (August 28 to October 22, 2023) in the ED of a large, urban, academic safety net hospital in the US. Participants included ED physicians, nurses, and other HCWs, who were asked to complete a brief so-called shift sheet for every ED shift worked during the study period. WPV as recorded on shift sheets. The primary outcome was the number of events per shift. Events were coded for severity (types 1-5) and gender- or race and ethnicity-related bias. Shift sheets asked for the participant's demographics and whether they experienced verbal or physical abuse during the shift. If so, they were asked to provide a description; rate the impact the event had on them; and indicate whether they felt the event was sexist, racist, or otherwise biased. Perceived impact was recorded, and demographic characteristics associated with the likelihood of experiencing WPV were explored using multivariable logistic regression analysis. Among 72 HCWs who participated in the study, 52 were female (72%). A total of 575 shift sheets were returned of an estimated 1250 possible (46%), with 155 events, including 77 type 1 events (50%; shouting, yelling, or insults), 29 type 2 events (19%; threats of physical or sexual violence, death threats, or use of slurs), and 39 type 3 events (25%; physical violence); there was a mean (SD) of 3.7 (1.9) shifts per 1 event. No type 4 or 5 events, which involve physical violence causing grievous injuries requiring medical attention and, in the case of type 5 events, permanent disability or death, were recorded. Ten events could not be coded. Sexist or racist bias occurred in 38 events (25%) and 11 events (7%), respectively. Participants reported how the event impacted them in 133 events. Of those, moderate or severe impact was reported in 32 (24%) and mild to no effect in 101 (76%). There was no association between self-reported impact and coded severity of events. In a multivariable logistic regression analysis, a higher likelihood of experiencing WPV on any given shift was independently associated with being in the nursing role (odds ratio, 3.1; 95% CI, 1.9-5.0) and being age 40 years or younger (odds ratio, 2.0; 95% CI, 1.2-3.5). In this cross-sectional study of HCWs in the ED, participants experienced WPV once every 3.7 shifts. The nursing role and younger age were associated with increased risk. These results highlight an urgent need to identify interventions to support and protect HCWs.

Self-Collection for Primary HPV Testing: Acceptability in a Large Urban Emergency Department

Overdue cervical cancer screening increases the risk of invasive cervical cancer. It is important to identify settings where self-collection for primary human papillomavirus (HPV) testing can be implemented to have high effect on cervical cancer screening among hard-to-reach women with overdue screening. Herein, we examined the acceptability of HPV self-collection, including completion rates, attitudes, and experiences among women seeking noncritical care at a high-volume urban safety-net hospital emergency department (ED) in Houston, Texas, United States. In this single-arm intervention pilot study, we recruited women overdue for cervical cancer screening in the waiting areas of a safety-net hospital ED, seeking noncritical care from November 2023 to April 2024. Participants completed a preintervention survey and were offered an HPV self-collection kit. A postintervention survey followed immediately after HPV self-collection. Nearly 30% (119 of 401) screened for eligibility were overdue for cervical cancer screening. Of these, 93% were enrolled and were predominantly Hispanic, non-US born, and uninsured, with a median age of 45 years (IQR: 37 to 53). HPV self-collection completion rate was 90% (95% CI 82.9% to 94.9%). More than a quarter (27%) of these women had never been screened, and 14% had a screening >10 years prior. Most women who completed the HPV self-collection had positive attitudes and experiences and reported that the kit was easy to use (97%) and would be very willing to use HPV self-collection for regular screening (88%). HPV self-collection for primary cervical cancer screening during noncritical ED visits is possible and highly acceptable among women overdue for cervical cancer screening.

Reported recreational drug and new psychoactive substance use versus laboratory detection of substances by high-resolution mass spectrometry in patients presenting to an emergency department in London with acute drug toxicity

Introduction Clinicians managing patients with acute recreational drug or new psychoactive substance toxicity typically depend on self-reported drug(s) used. This study compares patient self-report (and/or from other sources) to the substance(s) that were subsequently identified in serum. Methods A prospective sample of 1,000 adults presenting to a tertiary care, urban emergency department in London, United Kingdom, with acute recreational drug/new psychoactive substance toxicity was collected from 1 February 2019 to 2 February 2020. A total of 939 appropriate samples underwent qualitative analysis by high-resolution mass spectrometry with comparison to a database of drugs/metabolites. Data on the stated drug(s) used were extracted from the routine medical chart/records; results were batched by drug class, when appropriate, and analysis was performed using R software. Results Seven hundred and ninety-nine (85.1%) patients were male with a median (IQR) age of 34 years (27 to 42 years). Six hundred and thirty-five (67.6%) patients reported using two or more drugs. The median (IQR) positive predictive value of a self-report substance having been taken was 0.68 (IQR: 0.44–0.86); conversely, the median negative predictive value of a substance having not been taken was 0.90 (IQR: 0.53–0.95). There was variability in the accuracy of reporting. For example, self-reported opioid use had a 90.5% likelihood that opioids were detected on analysis, whereas hallucinogens were only detected in 18.8% of samples when use was reported. Individuals were also mostly accurate in not underreporting substances. For example, those not explicitly reporting gamma-hydroxybutyrate use were 97.5% truly negative. Discussion Overall, most users were relatively accurate in their self-report of what class of drugs they had used, although there was variability in this accuracy. However, other drugs were present even when not reported, for example, opioids with disproportionate detection of prescription and over-the-counter (non-prescription) opioids that were unreported. Conclusions Self-report (and/or collateral reports) had overall relatively high concordance with the likelihood that a substance was, or was not, recently used. Therefore, clinicians can make initial treatment decisions based on the self-reported drug(s) used in most cases.

Performance evaluation of the Abbott Alinity Hepatitis C antigen next assay in a US urban emergency department population

IntroductionHCV antibody assays have been used to screen for HCV, but confirmation of acute infection is dependent on RNA or core antigen testing. The aim of the study was to compare the performance of five HCV test methods, including RNA testing, on a US emergency department population. MethodsClinical performance metrics were calculated on 708 consenting Johns Hopkins Emergency Department patients who self-reported an increased risk for HCV infection. Detection times of antibody, antigen, and RNA testing were compared using 89 samples from commercially available seroconversion panels. Testing was performed on the Abbott Alinity HCV Ag Next (RUO), Roche Elecsys HCV Duo, Abbott ARCHITECT Anti-HCV, and Elecsys Anti-HCV II assays. RNA testing was performed on the Abbott m2000 system. ResultsOverall, 21 (3.0%) participants tested positive for HCV on at least one test, 11 (52.4%) had chronic, 1 (4.8%) had an acute, and 3 (14.3%) had resolved infections. The Alinity HCV Ag Next assay demonstrated 99.43% specificity when compared to RNA testing. The Alinity HCV Ag Next assay also detected 91.67% of the active infections compared to RNA testing, while the Elecsys HCV Duo Ag assay detected only 58.33%. The seroconversion panel testing demonstrated that the Alinity HCV Ag Next assay detects an infection within 0.8 days of an RNA result. ConclusionThe Alinity HCV Ag Next assay demonstrated excellent concordance to RNA testing in a US urban E.D. population. This data supports the utility of Alinity HCV Ag Next in diagnosis of active HCV infections.

“The stay here is, of course, not appropriate for an old person”: the perspective of healthcare providers on older patients in the emergency department

BackgroundIn aging societies, emergency departments (ED) face an increasing number of older, geriatric patients. Research shows that older emergency patients have a greater burden of comorbidities and a higher risk of adverse events. It has been questioned whether contemporary ED structures can meet the specific needs and characteristics of older patients. Little is known about how professional health care providers perceive and experience ED care for older patients. This study aimed to get insight into the perspective of healthcare providers working with older ED patients and to explore the challenges they experience in their daily work.MethodsThe study used a qualitative research design with a social-constructivist perspective and a Grounded Theory based methodology. Data were collected through qualitative interviews with N = 25 healthcare providers from different urban EDs in Berlin, Germany, and adjacent healthcare institutions. Following the Ground Theory approach, categories and central themes were identified, analyzed, and interpreted to gain a comprehensive understanding of the healthcare provider perspective.ResultsThe interviews revealed a significant and increasing relevance of geriatric ED patients for healthcare providers. However, there was no shared definition of ‘the geriatric patient’. Most interviewees found ED structures to be inadequate for older patients. They described specific challenges, such as information gathering and safety risks in the ED, as well as an increased use of resources (both time and personnel) when caring for older patients. In addition, specific problems in the collaboration with other professions and institutions were addressed, namely nursing homes, hospital wards, consultations, and the hospital social service.ConclusionHealthcare providers experience a structural mismatch between contemporary EDs and the specific needs of geriatric patients. They are aware of the vulnerabilities of geriatric patients and try to compensate for inherent structural shortcomings. Such structures and limited resources often cause practical, organizational, and ethical problems. There is a great need to develop, implement, and evaluate systematic approaches and care concepts that address the specifics of ED care for geriatric patients.

The relations between impulsivity, opioid use, and nonmedical prescription opioid use motives: An examination within three large urban emergency departments.

Impulsivity is a transdiagnostic risk factor for multiple disorders, including opioid use disorders (OUDs). However, scant work has examined if impulsivity facets distinguish individuals reporting nonmedical opioid use from those who use opioids as prescribed, particularly in important settings such as emergency departments (EDs). Further, no studies, to our knowledge, have examined the relations between impulsivity facets and motives for nonmedical prescription opioid use (NMPOU). Using data from EDs, this study examined if impulsivity facets (assessed via the [negative] urgency, premeditation, perseverance, sensation seeking, and positive urgency) related to nonmedical opioid use and if these facets related to OUD severity among individuals reporting past-year opioid use. Among patients reporting past 3-month NMPOU, the relation between motives for use and impulsivity was examined. Results indicated all facets (except lack of perseverance) distinguished patients reporting nonmedical opioid use from individuals abstaining from opioid use and those who used opioids as prescribed, with particularly large effect sizes for positive and negative urgency. Similarly, among patients reporting past 12-month opioid use, all facets (except lack of perseverance) significantly distinguished individuals who were OUD negative from those with severe OUD, with positive and negative urgency showing the strongest relations. Multiple motives were associated with certain UPPS-P facets, particularly positive urgency, negative urgency, and sensation-seeking. Results suggest that the relation between impulsivity and opioid use characteristics varies across facets of impulsivity, with emotion-based impulsivity being the most relevant. Implications for screening and interventions are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults.

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care. Setting: A medium-sized urban ED with 55,000 patient visits a year. Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail. From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates. Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

Association of Angiotensin Converting Enzyme Phenotypes and Polymorphisms with Clinical Outcomes in SARS-CoV2 Patients with Hypertension in an Urban Emergency Department.

The role of Angiotensin-converting enzyme (ACE and ACE2) phenotypes and polymorphisms in modulating severe acute respiratory syndrome coronavirus (SARS-- CoV2) infection in hypertensive patients remains unclear. Our objective was to determine the distribution of ACE and ACE2 receptor phenotypes by patient demographics and correlate ACE and ACE2 levels of activity with SARS-CoV-2 outcomes. Hypertensive patients treated for SARS-CoV-2 at an urban emergency department (ED) were prospectively enrolled in a cohort study between August 2020 and April 2021. Blood samples were collected during ED visits or hospitalization. Outcome measures including hospitalization, intensive care unit (ICU) admission, and 30-day mortality were obtained from electronic health records. Multivariable logistic regression was used. Of the 150 patients enrolled, 60% were Black, 32% Hispanic/Latinx, 4% Non-Hispanic Whites, and 4% others. The mean age was 59 (+/-14) years. The rate of hospitalization was high (86%) and Hispanic/Latinx had a higher likelihood of ICU admission. Patients harboring the rs2285666 genotype TT, AA, and GC alleles were more likely to be admitted to ICU, and those with TT and AA had higher mortality. The ACE level was a significant predictor of hospitalization with a protective effect in both unadjusted and adjusted results. Hispanics/Latinx had a four times higher likelihood of ICU admission compared to all others, and age was significantly associated with 30-day mortality. Our results show that even after adjusting for age, race, and sex, ACE levels remained a predictor of hospitalization. ACE/ACE2 phenotypes and genotypes potentially play an important role in disease progression in SARS-CoV-2 patients.

The Impact of Tele-Stewardship on Rural Antibiotic Prescribing Practices

Abstract Background Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. There has been limited research on the effectiveness of tele-stewardship in the outpatient setting. In this study, we address the need for better AS in rural areas by developing, implementing, and evaluating AS interventions using tele-stewardship. Methods We employed bundled outpatient AS implementation strategies in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center (VUMC) using tele-stewardship. The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls on common pediatric infections, communication skills training (DART modules), app-based microlearning modules (QuizTime), and implicit/explicit bias education and (4) quarterly audit and feedback with peer comparison on guideline-concordant antibiotic use. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children &amp;lt;18 years collected during the “baseline” period (Jan-Dec 2022) to the intervention period (Jan-Sept 2023). Two academic urban primary care clinics and one academic urban ED at which the interventions were not implemented were included as “control” sites. The primary outcome is percent of all encounters that result in an antibiotic prescription. Pre- and post-intervention data were analyzed in aggregate (not at the provider-level). Significance was determined via calculating a 95% confidence interval (CI) for the difference of proportions. Results To date, there have been 140,077 PC patient encounters (98,409 baseline and 41,065 intervention) and 94,205 ED encounters (61759 baseline and 32,446 intervention) across all sites. Change from baseline to intervention periods in academic PC sites was 0.9 percentage points (95% CI 0.556 to 1.243; 6.6% baseline, 7.5% intervention) while change in rural intervention sites was -1.05 percentage points (95% CI -0.409 to -1.667; 11.8% baseline, 10.75% intervention; Figure 1a). Only 1 of 3 rural EDs had a decrease in percent of encounters with an antibiotic prescription (Figure 1b). Overall the academic ED showed a 3.1 percentage point increase (95% CI 2.430 to 3.769; 18.0% baseline, 21.1% intervention) while the rural sites showed a 1.0 percentage point increase (95% CI -0.817 to 2.817; 24.2% baseline, 25.2% intervention). Conclusion Interim analysis shows that bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural primary care clinics compared to urban academic control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

Understanding Experiences of Headache-Sufferers Attending Emergency Departments Through Photovoice.

Our aim was to explore the experiences of individuals receiving emergency department (ED) care for acute headaches. Patients with headache exacerbations commonly present to EDs. This study explored the experiences of adult patients during the exacerbation period, specifically using photovoice. Recruited from two urban EDs in Alberta, Canada, participants with primary headaches took photographs over 3-4 weeks and subsequently completed a 60-90 minute, one-on-one, in-person photo-elicitation interview. Interviews were audio recorded, transcribed and thematically analyzed alongside photographs. Eight participants (six women) completed the study. The average age was 42 years (standard deviation: 16). Five themes emerged: (1) the struggle for legitimacy in light of the invisibility of their condition; (2) the importance of hope, hopelessness and fear in the day-to-day life of participants; (3) the importance of agency and becoming "your own advocate"; (4) the struggle to be and be seen as themselves despite the encroachment of their headaches; and (5) the realities of "good" and "bad" care in the ED. Participants highlighted examples of good care, specifically when they felt seen and believed. Additionally, some expressed the acute care space itself being a beacon of hope in the midst of their crisis. Others felt dismissed because providers "know it's not life or death." This study highlighted the substantial emotional impact that primary headaches have on the lives of participants, particularly during times of exacerbation and while seeking acute care. This provides insight for acute care settings and practitioners on how to effectively engage with this population.

426 Missed Diagnosis of Mild Traumatic Brain Injury: Retrospective Study in an Urban Emergency Department

426 Missed Diagnosis of Mild Traumatic Brain Injury: Retrospective Study in an Urban Emergency Department

125 Buprenorphine or Methadone: A Qualitative Analysis of Patient Preference in an Urban Emergency Department

125 Buprenorphine or Methadone: A Qualitative Analysis of Patient Preference in an Urban Emergency Department

Reasons Explaining High Emergency Department Use in Patients With Mental Illnesses: Different Staff Perspectives.

For patients with mental illnesses (MIs), emergency departments (EDs) are often the entry point into the healthcare system, or their only resort for quickly accessing mental health treatment. A better understanding of the various barriers justifying high ED use among patients with MIs may help recommend targeted interventions that better meet their needs. This explorative qualitative study aimed to identify such barriers and the solutions brought forth to reduce ED use based on the perspectives of clinicians and managers working in EDs, other hospital departments or the community sector. Interviews were conducted between April 2021 and February 2022; 86 mental health professionals (22% were nurses) from four large urban ED sites in Quebec (Canada) were interviewed. Barriers were identified in relation to patient profiles, healthcare system and organisational features and professional characteristics. The key barriers that were found to explain high ED use were patients having serious MIs (e.g., psychotic disorders) or social issues (e.g., poverty), lack of coordination and patient referrals between EDs and other health services, insufficient access to mental health and addiction services and inadequacy of care. Very few solutions were implemented to improve care for high ED users. Better deployment of ED interventions in collaboration with outpatient care may be prioritised to reduce high ED use for patients with MIs. Improvements to the referral and transfer processes to outpatient care, particularly through care plans and case management programs, may be implemented to reduce high ED use and improve outpatient care among patients with multiple health and social needs.

Impact of an Education Module on the Knowledge and Attitudes of EM Physicians Towards Prescribing Buprenorphine/Naloxone for Opioid Use Disorder.

Opioid overdose continues to be a major cause of morbidity and mortality. Buprenorphine is an important treatment for patients with opioid-use disorder (OUD) and initiation in the emergency department (ED) has been shown to improve outcomes for these patients. Our objective was to assess the impact of a three-pronged education package on the knowledge and attitudes of emergency physicians towards using buprenorphine for treatment of OUD. Procedures/data/observations: We developed a three-pronged educational package including back- ground rationale for OUD treatment with buprenorphine, an evidence-based ED buprenorphine induction pathway and electronic medical record tools. This package was deployed to providers in an urban academic ED. A voluntary confidential pre-post survey was administered. Using a 6-point Likert Scale, participants were asked about their understanding, experience, and confidence with prescribing. A one-hour, three-pronged educational package changed the attitudes of emergency physicians towards buprenorphine treatment and demonstrated an increase in willingness and confidence to prescribe it for patients with OUD. Our findings suggest that healthcare entities that wish to boost buprenorphine prescribing can impact willingness and confidence to prescribe with a short education package.

Lean-Based Approach to Improve Emergency Department Throughput.

Objective:Lean methodology can be utilized to increase throughput in a fast-track care area without changing staffing in a busy, urban emergency department (ED). Methods: A retrospective before-and-after analysis was performed to an improvement process in a fast-track care area within an ED with a census of 100,000 patients. The intervention utilized Lean methodologies to identify inefficiencies in the throughput model set for patients triaged to fast-track. Multiple ED stakeholders were involved in formulating a more efficient framework for how patients would receive care when triaged to fast-track. Results: There was a decline in the patient's overall length of stay (-9%, p=0.08), arrival to the room (-10%, p=0.4418), and ED attending to disposition (-9%, p=0.003). Additionally, all aspects of patients leaving prior to treatment completion (against medical advice (-29.4%, p=0.006), elopement (-20.4%, p=0.049), and left without being seen (-5.3%, p=0.11)) declined. Discussion:Identifying wasted time and resources in a patient's stay in the ED allowed for a more efficient throughput model to be developed. This resulted in patients being able to be seen in a more methodical manner leading to decreased wait times and lower left without being seen rates. Conclusion: A Lean-based throughput model was implemented to improve efficiency, reducing the length of stay and increasing the volume of patients evaluated per shift without additional costs. This improvement led to fewer patients leaving before treatment and demonstrated the value of process improvement in healthcare.

State program enables the identification of factors associated with naloxone awareness, self-efficacy, and use for overdose reversal: A cross-sectional, observational study in an urban emergency department population

IntroductionTo assist the state of Ohio in addressing the opioid epidemic, the Ohio Attorney General appointed experts in a variety of academic disciplines to the Scientific Committee on Opioid Prevention and Education (SCOPE). The focus of SCOPE is the application of scientific principles to the development of prevention and educational strategies for reducing substance use disorder and related harms (e.g., promoting naloxone awareness). Naloxone awareness is a step in the naloxone cascade, which is a useful model for understanding the sequential steps laypeople must take to prepare themselves to intervene using naloxone; other steps include training and previous administration experience. Prior work has explored correlates of these steps among individuals with risky substance use, but fewer studies have focused on broader populations containing potential bystanders (e.g., family and community members). MethodsThis study was a secondary data analysis of patients from three urban emergency departments. Subsamples differed across five models (n = 479–1208) and included opioid-exposed and -naïve participants. Logistic regression characterized clinically useful sociodemographic predictors (e.g., race, ethnicity, education, employment, housing status) of naloxone awareness, self-efficacy (which relates to training), and previous-overdose administration. Two additional logistic regressions tested associations between risk factors for witnessing an opioid overdose and two cascade steps (awareness and self-efficacy). ResultsNon-White race, Hispanic ethnicity, and lower education predicted not being aware of naloxone; non-White race also predicted lower naloxone self-efficacy, and older age predicted lack of previous-overdose administration. Having family members with risky opioid use was heavily associated with awareness, while personal substance-use behaviors and previous overdose witnessing were associated with both awareness and higher naloxone self-efficacy. ConclusionsCharacteristics associated with lower likelihood of completing each cascade step highlight opportunities for targeted interventions. Specifically, findings indicated the importance of expanding naloxone education and training programs to more diverse populations and to family members of individuals with risky opioid use. Further, these findings demonstrate how a state-funded program such as SCOPE can have a positive impact on identifying strategies that may assist in reducing mortality associated with opioid overdose.

‘Get tested Leeds’: new HIV diagnoses via bloodborne viruses (BBV) testing in urban emergency departments (ED)

‘Get tested Leeds’: new HIV diagnoses via bloodborne viruses (BBV) testing in urban emergency departments (ED)

Association of genetic variants in CYP3A5, DRD2 and NK1R with opioid overdose

In 2023, 3651 Ohioans died because of an opioid overdose. Of those opioid overdoses, 3579 (98%) of which were attributed to fentanyl. We evaluated the association between 180 candidate single nucleotide polymorphisms (SNPs) and self-reported, nonfatal opioid overdose history from a prospective sample of 1301 adult patients (≥18 years of age) seen in three urban emergency departments in Ohio. Candidate SNPs included 120 related to the dopamine reward pathway and 60 related to pharmacokinetics. Of the 821 patients who reported having been exposed to opioids in their lifetime, 95 (11.6%) also reported having experienced an opioid-related overdose. Logistic regression, adjusting for age and biologic sex, was used to characterize the association between each SNP and opioid overdose, correcting for multiple comparisons. Three SNPs, located in three different genes were associated with opioid overdose: increased odds with CYP3A5 (rs776746) and DRD2 (rs4436578), and decreased odds with NKIR (rs6715729). Homozygotic CYP3A5 (rs776746) had the highest adjusted odds ratio (OR) of 6.96 (95% CI [2.45, 29.23]) and homozygotic NK1R (rs6715729) had the lowest OR of 0.28 (95% CI [0.14, 0.54). Given that CYP3A5 (rs776746) has been associated with increased plasma concentrations of fentanyl, rs776746 could potentially be utilized as a prognostic risk indicator for the potential of an opioid overdose. NK1R regulates the expression of the neurokinin-1 receptor, a regulator of respiration and NK1R (rs6715729) represents a novel genetic marker for a decreased risk of opioid overdose risk.