Urgent Care Research Articles

61 The HEADS-ED under 6: Validation of a mental health and developmental screening and triage tool

Abstract Background The HEADS-ED screening and triage tool was developed for children 6 years to young adults as a communimetric mental health (MH) and addictions screener to help clinicians identify and communicate areas of need and recommended clinical care. Few clinician-administered tools identify both MH and developmental needs in young children under 6. From a review of milestone tools and in consultation with paediatricians, psychiatrists, and family physicians, the HEADS-ED Under 6 is a MH and developmental screening and triage tool that was developed to screen and flag functional impairment and action required in several areas, including: Home & caregivers, Eating & sleeping, Activities & peers, Development /speech/language/motor, Safety, Emotions & behaviours and Discharge & current resources (see http://heads-ed.com for more background and access to both tools available in English and French). Objectives Our objectives were to examine: 1) feasibility of implementing the new HEADS-ED Under 6 screening and triage tool in community and hospital settings, 2) clinical utility of the tool to assist with clinical decision making, and 3) validity of the tool against a comprehensive assessment. Design/Methods We conducted two implementation and validation studies to examine uptake of the tool and how the tool assists in clinical referral decisions to more specialized and intensive services at 2 sites. For our initial validation study, we piloted and validated the tool at a community MH agency in Ontario for children under the age of 6 from November 2019- March 2021 (N=566). For our cross-validation study, we examined how the tool was implemented within a regional coordinated access service housed in a paediatric hospital in Ontario from June 2021- August 2023 (N=589). Results For our initial validation study, the HEADS-ED Under 6 was widely used by intake workers (95%, N = 536/566) to communicate children’s MH and developmental needs (Figure 1) and assisted in recommending services of varying intensity. The tool showed good concordance with the InterRAI Early Years assessment in similar domains requiring no action (61.1% to 81.6%), requiring action but not immediate (49.2% to 88.0%) and requiring immediate action (66.7% to 100%) for children under 4 years old (p's <.001). Three clinical domains (Eating & sleeping, Development/speech/language/motor, and Emotions & behaviours) also independently predicted an urgent care recommendation (p's < .001). For our cross-validation study, the tool was used for all 589 intake appointments, and 96.4% (N = 568/589) had a level of need documented. HEADS-ED Under 6 clinical domains (.24-.38) and total scores (.52) were significantly correlated with level of need (p<.001). Higher HEADS-ED Under 6 total scores helped intake workers decide on more intense services based on level of need (p<.001; Figure 2). ROC analyses (AUC = .807, SE = 68.5% sensitivity, 79.5% specificity) confirmed a total score of 6 or above helped triage to more targeted and intense services. Conclusion The HEADS-ED Under 6 is a brief, straight-forward, and valid screening and triage tool that can be used by intake workers, physicians, and paediatricians to guide their interview in several areas of MH and development, communicate the severity of the child’s MH and developmental needs, and assist with determining level of need for services. When a HEADS-ED Under 6 total score reaches ≥6, clinicians should advocate for more intensive services when making MH service referrals.

Evaluating the relationship between heat-related illness and cooling center location in Virginia

AbstractExtreme heat contributes to adverse health outcomes and public cooling centers are often used as both a heat-health mitigation and management strategy to protect public health during extreme heat events. While the presence of a cooling center should theoretically improve heat-health outcomes in the surrounding community, there are no quantitative studies evaluating this relationship. Using heat-related emergency department and urgent care center visits from the 2014–2020 summer seasons, this study evaluates the relationship between heat-related illness (HRI) and cooling centers in Virginia. In total, more than 10,000 incidences of HRI occurred over the period across 68% of Virginia ZIP codes as reported. Communities with a cooling center had higher rates of HRI than those without, and this difference was most significant in urban areas. This result was coincident with a significant increase in non-white residents in these ZCTA. Our results draw attention to the need for additional research on the topic of cooling center access, efficacy, and operations. Strategically locating cooling centers near or within vulnerable communities is one just consideration, and more work is needed to uncover if, when, who, and how communities are utilizing, or in many cases not utilizing or unable to utilize, cooling centers.

The most common neonatal presentations to the pediatric emergency department

Introduction The first 28 days of life are considered the neonatal period, when pediatric health is most vulnerable. While crises can undoubtedly arise during this time, many ED or urgent care visits could be avoided with sufficient preventive hospital care during the newborn period and suitable follow-up with a primary care physician. The use of emergency rooms for non-urgent care could be the cause of rising healthcare costs and ineffective resource use. Purpose This study aimed to determine the presenting features, management, and disposition of neonatal attendance in the emergency department. Methods This was a retrospective observational cross-sectional study of medical records identified via the emergency department of neonatal visits (≤28 days) to King Fahd Hospital of the University (KFHU), Khobar, Saudi Arabia, over 12 months (2021–2022). The Chi-square test was performed to compare various etiologies, with a 5% significance level. Results A total of 649 neonate visited pediatric emergency department with a mean age of 15.5 ± 7.4 days and almost equal distribution of the gender. The most common presentation was upper respiratory tract infection (URTI) (26.8%), followed by physiological jaundice (20.2%), and colic (14%). A total of 205 (31.6%) neonates who visited the ED showed significant laboratory findings. Seventy-nine patients (12.2%) presenting with PED were admitted to the hospital. Conclusion Healthcare systems must devise strategies to address the growing number of non-urgent visits to emergency departments in a more efficient manner, while simultaneously reallocating scarce resources to higher-acuity cases. This emphasizes the necessity of health personnel educating caregivers. It’s also critical that medical professionals understand the common ailments that affect newborns and are skilled at correctly identifying ailments that could indicate a serious pathology.

Interfacility Transfer of Children With Time-Sensitive Surgical Conditions, 2002-2017

Surgical care for children in the United States has become increasingly regionalized among fewer centers over time. The degree to which regionalization may be associated with access to urgent surgical care for time-sensitive conditions is not clear. To investigate whether transfers and travel distance have increased for 4 surgical conditions, and whether changes in transfers and travel distance have been more pronounced for rural vs urban children. This retrospective cross-sectional study analyzed data from 9 State Inpatient Databases from 2002 to 2017. Participants included children aged younger than 18 years undergoing urgent or emergent procedures for malrotation with volvulus, esophageal foreign body, and ovarian and testicular torsion. Residential and hospital zip codes were categorized as rural or urban. Hospitals were categorized as pediatric hospitals, adult hospitals with pediatric services, and adult hospitals without pediatric services. Primary outcomes were transfer for care and travel distance between patients' home residences and the hospitals where care was provided. Transfer and travel distance were analyzed using multivariable regression models. Among the 5865 children younger than 18 years undergoing procedures for malrotation with volvulus, esophageal foreign body, ovarian torsion, or testicular torsion, 461 (7.9%) resided in a rural area; 1097 (20.5%) were Hispanic, 1334 (24.9%) were non-Hispanic Black, and 2255 (42.0%) were non-Hispanic White; 2763 (47.1%) were covered by private insurance and 2535 (43.2%) were covered by Medicaid; and the median (IQR) age was 9 (2-14) years. Most care was provided at adult hospitals (73.4% with and 16.9% without pediatric services); the number of hospitals providing this care decreased from 493 to 292 hospitals (2002 vs 2017). Transfer was associated with rural residence (adjusted odds ratio [aRR], 2.3 [95% CI, 1.8-3.0]; P < .001) and increased over time (2017 vs 2002: aOR, 2.8 [95% CI, 2.0-3.8]; P < .001). Similarly, travel distance was associated with rural residence (adjusted risk ratio [aRR], 4.4 [95% CI, 3.9-4.8]; P < .001) and increased over time (2017 vs 2002: aRR, 1.3 [95% CI, 1.2-1.4]; P < .001). Rural children were more frequently transferred (2017 vs 2002) for esophageal foreign body (48.0% [12 of 25] vs 7.3% [4 of 55]; P < .001), ovarian torsion (26.7% [4 of 15] vs 0% [0 of 18]; P = .01), and testicular torsion (18.2% [2 of 11] vs 0% [0 of 16]; P = .04). Travel distance for rural children increased the most for torsions, from a median (IQR) of 19.1 (2.3-35.4) to 43.0 (21.6-98.8) miles (P = .03) for ovarian torsion and from 7.3 (0.4-23.7) to 44.5 (33.1-48.8) miles (P < .001) for testicular torsion. In this cross-sectional study of children with time-sensitive surgical conditions, the number of hospitals providing urgent surgical care to children decreased over time. Transfers of care, especially among rural children, and travel distance, especially for those with ovarian and testicular torsion, increased over time.

Churning the tides of care: when nurse turnover makes waves in patient access to primary care

BackgroundTeam-based primary care (PC) enhances the quality of and access to health care. The Veterans Health Administration (VHA) implements team-based care through Patient Aligned Care Teams (PACTs), consisting of four core members: a primary care provider, registered nurse (RN) care manager, licensed vocational nurse, and scheduling clerk. RNs play a central role: they coordinate patient care, manage operational needs, and serve as a patient point of contact. Currently, it is not known how varying levels of RN staffing on primary care teams impact patient outcomes.ObjectiveThis study aims to empirically assess how the stability of RN staffing within team-based primary care affects patient access to care.MethodsA retrospective database review using clinical and administrative data from the VHA over 24 months. Participants included 5,897 PC PACTs across 152 VHA healthcare facilities in the United States and its territories. The stability of personnel in the RN role was categorized as: RN continuous churn, RN staffing instability and RN vacancy. All 3 categories were compared to teams with RN stability (i.e., same person in the role for the entire 24-month period). Access measures included: average third-next-available appointment, established patient average wait time in days, urgent care utilization, emergency room utilization, and total inbound-to-outbound PC secure messages ratio.ResultsRN continuous churn within PACTs had a significant impact on third-next-available appointment (b = 3.70, p < 0.01). However, RN staffing instability and vacancy had no significant relationship with any of the access measures. Several risk adjustment variables, including team full-time equivalency, team stability, relative team size, and average team size, were significantly associated with access to health care.ConclusionsTeams are impacted by churn on the team. Adequate staffing and team stability significantly predict patient access primary care services. Healthcare organizations should focus on personnel retention and strategies to mitigate the impact(s) of continuous RN turnover. Future research should examine the relative impact of turnover and stability of other roles (e.g., clerks) and how team members adapt to personnel changes.

Construction and validation of the Emergency Oncology Scale (EMOnco), a risk rating protocol for the triage of cancer patients in acute care settings.

Manfredini et al. demonstrate that the new rating protocol, EMOnco, can triage of cancer patients in acute care settings safely, considering their cancer type, stage and treatment histories and oncological emergencies, enabling the appropriate classification from high-risk patients to non-urgent patients. ■ EMOnco considers variables related to the cancer history and treatment. ■ Triages patients in the emergency care in less than three minutes. ■ Cancer patients need priority care regarding infection, and this protocol consider it. ■ EMOnco has shown to be a valid and reliable scale for the triage of oncological patients in the emergency room or acute care clinics. To validate a risk rating scale for triaging of cancer patients in emergency rooms that can identify individuals needing urgent care or in imminent worsening of the clinical condition. This is a health instrument validation study developed in the emergency care ward of a Brazilian hospital, a referral center for cancer and hematological diseases. We built the Emergency Oncology Scale (EMOnco) based on literature review and a Delphi survey with 20 experienced oncologists (physicians and nurses). We validated the scale by assessing its construct validity, interobserver agreement and reliability after applying them in a convenience sample of all consecutive patients with cancer who visited the ward between August 2017 and January 2018. We compared the EMOnco Scores with those from other scales, used by six trained nurses: the Emergency Severity Index, the Manchester Triage System, and the Karnofsky Performance Status. We also recorded socio-demographic and clinical features and the Sequential Organ Failure Assessment (SOFA) results in the intensive care unit. We included 250 patients with locally advanced or recurrent disease and undergoing chemotherapy. EMOnco screening took 2.24 (± 2.9) minutes in average. The interobserver correlation coefficient was 0.9. EMOnco was highly correlated with Emergency Severity Index (r=0.617) and also correlated with Karnofsky Performance Status (0.420) Manchester Triage System (0.491; p<0.001 for all). EMOnco in Portuguese considers variables related to the cancer history and treatment and has proven to be a valid and reliable for the risk classification of oncological patients in emergency care services.

Self-reported Health Service Utilization and Barriers to Care Among US Adults with a History of Post COVID-19 Condition.

Millions of US adults continue to experience symptoms of post COVID-19 condition (PCC). More data on health service utilization patterns and barriers to care in this population are needed to understand how to care for people with PCC. To evaluate health service utilization and barriers to medical care among individuals with a history of PCC compared with other US adults. Data were analyzed from the 2022 National Health Interview Survey (NHIS), a nationally representative, cross-sectional survey of the US population. US adults. Health service utilization and the presence of financial and nonfinancial barriers to care in the preceding 12 months. There were 24,905 individuals included in the analysis, representing approximately 230 million US adults. The weighted prevalence of those with a history of PCC was 6.9% (95%CI, 6.5-7.3). Compared to other US adults, participants with a history of PCC were more likely to have had an urgent care visit (adjusted odds ratio (aOR) 1.52 [95%CI, 1.34-1.72]), emergency room visit (aOR 1.94 [95%CI 1.71-2.21]), hospitalization (aOR 1.48 [95%CI, 1.24-1.77]), rehabilitation services (aOR 1.35 [95%CI, 1.14-1.60]), home care (aOR 1.55 [95%CI, 1.66-2.26]), mental health counseling (aOR 1.39 [95%CI, 1.17-1.65]), and complementary and integrative medicine services (aOR 1.29 [95%CI, 1.13-1.49]). Furthermore, respondents with a history of PCC were more likely to report at least one financial barrier to care (aOR 1.71 [95%CI, 1.48-1.97]) and at least one nonfinancial barrier (aOR 1.77 [95%CI, 1.56-2.00]). A greater proportion of participants with a history of PCC reported a financial barrier and nonfinancial barrier than adults with most other chronic conditions captured by NHIS. Individuals with a history of PCC were more likely to use a variety of health services and report barriers to medical care. Health systems should consider developing accessible, multidisciplinary care pathways for this population.

6572 Acute Adrenal Crisis Secondary To Undiagnosed Addison's Disease

Abstract Disclosure: J.M. Deirmenjian: None. H. Nickowitz: None. T. Kavafyan: None. Addison’s disease, also known as primary adrenal insufficiency, is when the adrenal gland has a defect in making cortisol. Signs and symptoms of Addison’s disease include nausea, vomiting, diarrhea, fatigue, dizziness, hyperpigmentation, and mood changes. Acute Adrenal Crisis can occur as a result of Addison’s disease when patients experience acute physiologic stress such as acute illness. Patient is a 35- year-old woman with a PMHx of iron deficiency anemia presenting with intractable nausea and vomiting for 10 days and a single witnessed syncopal episode two days prior to presentation. She was also had intermittent dizziness. Patient initially presented to urgent care where she was found to be hyponatremic and then was sent to the ED. She had no seizure like activity or rashes prior to admission. On initial physical exam, her skin was warm and dry with skin discoloration and hyperpigmentation. She was awake, alert, and oriented to person, place, time, and situation. Patient had no neurological deficits and no lateral or vertical nystagmus on initial assessment. On admission, patient was hyponatremic to 114 mEq/L, potassium was 5.0 mEq/L, and glucose level was 79 mg/dL. Despite receiving a 500 cc NS bolus, 1L NS bolus, 25 grams of albumin, and D5-0.45 NS at 50 cc/hr, the hyponatremia was difficult to correct. Her sodium initially corrected to 120 mEq/L but the sodium later decreased to 117 mEq/L. The morning after admission, patient became hypotensive and hypoglycemic. Random cortisol was measured and found to be 2.2 mcg/dL, raising concern for acute adrenal crisis as a result of undiagnosed Addison’s Disease. ACTH level was 17 pg/mL. Endocrinology was consulted and she was treated with IV 100 mg Hydrocortisone in addition to IV hydrocortisone 50 mg IV q6h. Patient was able to be transitioned to PO hydrocortisone 15 mg qAM and 5 mg qPM and was started on PO fludrocortisone 0.1 mg daily. On day of discharge, sodium improved to 127 mEq/L. CT Abdomen with contrast was completed to evaluate the adrenal glands and it showed a normal appearance of the adrenal glands. The etiology of the patient’s acute adrenal crisis was secondary to undiagnosed Addison’s Disease. It is interesting to note that patient was not hypoglycemic on admission but later became hypoglycemic during her hospital course. Adrenal crisis is a possible fatal complication of undiagnosed Addison’s disease. Therefore, a possible Addison’s Disease diagnosis is important to consider when patients are presenting with symptoms such as nausea, vomiting, dizziness, and electrolyte derangements including hyponatremia. If patient’s present with hyponatremia, ruling out possible adrenal insufficiency by checking a cortisol level may change the course of patient’s care. After discharge, she was able to establish care with Endocrinology and remain stable on treatment with PO hydrocortisone and PO fludrocortisone. Presentation: 6/3/2024

6687 Indicators of Diabetes Management: Predicting Unplanned Healthcare Utilization and Mortality in a Suburban Integrated Delivery Network

Abstract Disclosure: K.M. Barton: None. J.Y. Yip: None. K.C. Geckeler: None. A. Popelka: None. D.J. Ramsey: None. Purpose: To explore whether patients with diabetes mellitus (DM) who met Comprehensive Diabetes Care Healthcare Effectiveness Data and Information Set (HEDIS) metrics had a reduced likelihood of experiencing unplanned emergency department (ED) visits, hospitalizations, or mortality. Introduction: The prevalence of DM among U.S. adults is approximately 15% and continues to rise. To enhance care for individuals with DM, Comprehensive Diabetes Care HEDIS quality measures have been established. These measures encompass criteria such as blood pressure control, hemoglobin A1c (HbA1c) levels, and the completion of an annual eye examination. However, the connection of these metrics to health outcomes remains insufficiently studied. Methods: This study comprised a retrospective, cross-sectional exploratory analysis of established patients aged 18 years or older with DM receiving primary care within a suburban integrated delivery network (IDN). Multivariate logistic regression was used to analyze patient characteristics, including demographics, sociomedical factors, and biometrics. Outcome variables encompassed one or more unplanned ED visits (including urgent care), one or more unplanned hospitalizations, or mortality within the one-year study period. Results: Out of 28,929 patients with DM, 5293 (18.3%) had ≥1 ED visit, 3725 (12.9%) had ≥1 hospital admission, and 614 (2.1%) died during 2022. After controlling for available demographic and sociomedical factors, patients with poor HbA1c control (considered HbA1c &amp;gt; 9.0) in the year prior were more likely to experience an ED visit in the study year (adjusted odds ratio [aOR] = 1.292, 95% CI, 1.121-1.489, p &amp;lt; 0.001). Patients who achieved HbA1c control (considered HbA1c &amp;lt; 8.0) in the year prior were less likely to experience an ED visit (aOR = 0.845, 95% CI, 0.763-0.936, p = 0.001) and less likely to experience a hospitalization in the study year (aOR = 0.878, 95% CI, 0.779-0.989, p = 0.032). Patients who completed an eye exam in the year prior were less likely to experience a hospitalization (aOR = 0.913, 95% CI, 0.847-0.984, p = 0.017) or die (aOR = 0.694, 95% CI, 0.579-0.831, p &amp;lt; 0.001) in the study year. Finally, patients who completed microalbumin testing in the year prior were less likely to experience an ED visit (aOR = 0.902, 95% CI, 0.84-0.968, p = 0.004), or die (aOR = 0.464, 95% CI, 0.389-0.554, p &amp;lt; 0.001). Conclusion: Achieving HbA1c control in the previous year is linked to decreased likelihood of experiencing an unplanned ED visit or hospitalization. An eye exam in the year prior was associated with decreased likelihood of hospitalization or death. Further research into interventions aimed at enhancing DM management and reducing associated complications may have potential to enhance patient health outcomes while reducing health care costs. Presentation: 6/3/2024

The Ambulatory Diabetes Outreach Program (ADOP): Rigorous Evaluation of a Pharmacist and Nurse-Led Care Model.

Although several systematic reviews found that ambulatory diabetes mellitus (DM) interventions involving pharmacists generally yielded better outcomes than the ones that did not, existing studies have limitations in rigor and study design. To examine the intention-to-treat effects of the Ambulatory Diabetes Outreach Program (ADOP) on participants' A1c values and healthcare utilization over a 52-month follow-up period. Difference-in-differences with staggered adoption. Specifically, we employed the Callaway and Sant'Anna's "group-time average treatment effect" estimator using not-yet treated as controls adjusting for patient's age, BMI, sex, race, comorbidity, payor, and socio-economic status. All patients with at least one ADOP treatment encounter from July 2017 to October 2021, regardless of program completion or length of exposure to the program. ADOP, a collaborative population health program led by pharmacists and nurse specialists to provide individualized type 2 DM management and education within a large and diverse health system. Patients' A1c values and healthcare utilization, including inpatient admission, inpatient days, and numbers of visits to the emergency department, urgent care, and primary care in recent 6months. ADOP participation was associated with an overall average reduction of 1.04 percentage points (95%CI - 1.12, - 0.95) in A1c level. Similar A1c reductions were also observed in the subgroups by sex and race/ethnicity. An average of 2months were required to reach the overall average effect, which persisted over 4years. Compared to the respective utilization levels pre-intervention, participants also had average reductions in inpatient admissions by 32.4%, inpatient days by 81.6%, visits to the emergency department by 21.6%, and primary care by 17.9%. The results suggest that a collaborative model of pharmacist and nurse-led type 2 DM intervention was effective in improving A1c outcomes and reducing healthcare utilization in the long term.

A multicenter randomized control trial: Point-of-care syndromic assessment versus standard testing in urgent care center patients with acute respiratory illness.

Syndromic assessment with multiplex polymerase chain reaction (mPCR) testing in patients with acute respiratory illness (ARI) allows for simultaneous identification of multiple possible infectious etiologies. Point-of-care (POC) syndromic assessment can be conducted in a clinical setting, such as an urgent care center (UCC), without requiring certified laboratories. The primary objective of this study was to determine whether POC syndromic assessment improved patient satisfaction for patients seen at an UCC with ARI; secondary objectives included whether syndromic assessment reduced self-isolation time, increased diagnostic confidence, and reduced overall antibiotic utilization. We conducted an unblinded multicenter randomized controlled trial on UCC patients with an ARI. Patients were randomized to either SC (defined as standard UCC testing for ARI) or syndromic assessment with POC mPCR. Patients were surveyed for patient satisfaction, self-isolation plans, diagnostic confidence, and overall antibiotic utilization. Among the 360 patients enrolled, those in the syndromic assessment group were more satisfied with the time required to communicate the results (98.4%vs. 42.4%, p<0.001) on day of treatment, more likely to resume normal activities sooner (83.3%vs. 69.4%, p=0.039), and more confident in their illness cause (60.7%vs. 29.6%, p<0.001); however, the rate of antibiotic utilization did not differ (33.5%vs. 26%, p=1.0). In conclusion, our study provides evidence supporting the use of syndromic assessment in UCCs for ARI diagnosis, including patient-centered outcomes such as greater confidence in diagnosis and more efficient isolation strategies. This study did not show a difference in more clinically oriented outcomes, such as a change in antibiotic utilization. Future studies should identify clinical care pathways to improve antibiotic stewardship for likely viral syndromes and whether the increased initial cost of syndromic assessment is offset by the clinical benefits and subsequent cost savings.

Urgent palliative care: An effective intervention to improve end-of-life experience and outcomes for patients with advanced cancer.

203 Background: Early integration of palliative care services for advanced oncology patients has a well-documented benefit on quality-of-life measures including symptom management, quality-of-death measures, cost-effectiveness, care-giver burden, and patient satisfaction metrics. However many barriers exist, including delayed referrals and negative perceptions of hospice/palliative care by patients and families. Furthermore, wait times from referral to visit can vary from weeks to months. For patients with late-stage disease, rapidly advancing disease or symptoms, this delay can lead to unnecessary acute care utilization, impoverished quality-of-life, and discordant end-of-life care. Methods: The CU Cancer Center CARE clinic provides advanced symptom management and urgent care services to oncology patients, often seeing patients with high symptom burden and advanced disease. A recent unpublished case-based analysis demonstrated that patients seen in CARE clinic 4 times or more in a month have a high risk of inpatient mortality within 3 months. In response, the CARE clinic created an urgent palliative care program wherein patients have the ability to see a palliative care provider within 1 week of referral who could provide ongoing advanced symptom management/medication titration and facilitate conversations around goal-concordant care in late-stage illness. A 1-year feasibility pilot took place from 2022-2023. Referrals required patients to meet the following criteria: 1) Not already being seen by an ambulatory palliative care professional; and 2) any of the following: prognosis of weeks without an end-of-life care plan; symptoms likely to require hospitalization if not addressed within a week; or seen in CARE clinic 4 or more times in the last month From 09/2022-08/2023, 55 patients were seen. Outcomes were followed for 3 months following final CARE clinic visit and were compared to patients who had received palliative care referrals from the CARE clinic in the preceding year (9/2021-9/2022). Results: In-hospital deaths, hospital days in the last 30 days of life, and palliative care/hospice involvement were all positively affected in our initial pilot. Notably, in-hospital deaths were reduced by 50%. There was also a 14% increase in deaths with hospice care in the pilot group compared to the control group. Conclusions: Data from this feasibility pilot suggest that urgent palliative care can improve key metrics in oncology quality-of-care, and improve cost effectiveness. Further delineation of the outcomes compared in a rigorously controlled population will further define the relative clinical benefit and fiscal implications of such interventions. Urgent palliative care outcomes. Historical Control (2021-2022) Pilot (2022-2023) N 44 55 Hospitalizations 101 52 Deaths 30 (68%) 40 (72%) Deaths in the Hospital 8 (18%) 5 (9%) Deaths With Hospice Care 21 (47%) 34 (61%)

The evolution of a large-scale facial gender affirmation program: A comparative outcomes analysis

BackgroundThe volume of facial feminization surgery (FFS) performed has increased tremendously over the last decade as new gender affirmation programs have formed. Advancements in surgical planning and treatment protocols have resulted in complex, multiprocedural FFS operations. This study examines the characteristics and outcomes of a large-scale FFS program over a 5-year lifespan. MethodsA retrospective analysis was performed of all patients who underwent FFS in a high-volume integrated healthcare system from program initiation in 2018-2019 (early cohort) to maturation in 2021-2022 (late cohort). Patient charts were reviewed for demographic factors, operative details, complications, postoperative Emergency Department or Urgent Care (ED/UC) visits, revisions, and readmissions. Patient characteristics and outcomes were compared between early and late cohorts. Results191 patients were included, with 109 in the early cohort and 82 in the late cohort. Patient demographics were similar except mean age (40.3 years early cohort versus 36.3 years late cohort, p=0.03). Patients in the late cohort had longer operations (5.40hours versus 6.16hours, p=0.008) with a greater percentage of patients receiving genioplasty, rhinoplasty, fat grafting, or lip lift. Despite this, fewer patients in the late cohort were admitted postoperatively (62.4% versus 13.4%, p<0.001). There were no differences in total complications, minor complications, revisions, ED/UC visits, or readmissions. However, major complications were significantly more common in the early cohort (4.6% versus 0.0%, p=0.05). ConclusionAs a nascent FFS program matures, the number of procedures in a single operation increased along with operative length. Major complications and postoperative admission rates decreased while total complications remained low.

Community paramedicine program and outcomes of referred coronary artery bypass grafting patients.

Community paramedicine is a field in its infancy. The use of community paramedics has expanded in recent years as an alternative or adjunct to home health in the continued drive to decrease health disparities and complications. In current practice, they function in a position like a home healthcare nurse with an expanded scope of practice, such as providing specialized follow-up care, for example with postoperative care for patients who have undergone major surgery or recent hospitalization. This study assesses if community paramedics are a valid option in reducing rehospitalization of patients who underwent a coronary artery bypass grafting (CABG) procedure. A retrospective chart review between 2021 and 2022 was performed on all patients who underwent CABG in Bismarck, North Dakota, along with obtaining a referral for the community paramedics spanning urban and rural areas. A comparison was made between individuals who saw the community paramedics in their post-care versus those who continued with the standard of care. There were 80 participants and 38 location-matched controls. All variables were found to be statistically insignificant except for the number of walk-in visits (urgent care), in which 7 out of 38 sought medical attention in the controls and 4 out of 80 sought medical attention in the participants. The proportions of inpatient readmission rates and emergency department (ED) visits were similar. Given that paramedicine is in its infancy, the emergence of other variations of the community paramedic certification has brought a discussion of their scope of practice. While walk-in visits, even with the limitations, showed significant improvement with the addition of community paramedics, more research is still needed to show their effectiveness in reducing readmission to hospital. Additionally, the patients who sought help from community paramedics may be more likely than the controls to seek help from medical professionals. This study provided a novel look into the effect that community paramedics can have on patients in urban and rural areas in regard to reducing postoperative complications and minimizing unnecessary advanced healthcare utilization.

Analysis of ChatGPT in the Triage of Common Spinal Complaints

ChatGPT is a natural language processing chatbot with a significant prevalence in modern media with a clear application in the medical triage workflow. ChatGPT has shown significant capacity for understanding clinical vignettes, radiology reports, and even passing the American Board of Neurological Surgery board examination. There has never been an evaluation of the chatbot in triage and diagnosing spinal vignettes common to primary and urgent care practice. Fifteen clinical scenarios were created to mimic spinal complaints common to primary and urgent care scenarios. GPT-4 was instructed to assess the situation as if it was in a primary care office and determine diagnosis, imaging recommendations, and if emergency room (ER) or operative referral was necessary. Answers were recorded and the results compared to those of attending and resident respondents. GPT-4 provided the most likely diagnosis in each scenario. Additionally, it recommended reasonable clinical management of each scenario which would fall within standard practice guidelines. ChatGPT tended toward over-referral to the ER; however, this was not significant. GPT-4 was noninferior in all categories when compared to respondents. ChatGPT is a powerful tool for primary triage of spinal issues. It can rapidly and accurately evaluate clinical scenarios and provide clear diagnostic reasoning. GPT-4 is not designed for medical use and will provide a disclaimer as such. It did tend toward over-referring patients to the ER. With specific training, it is likely that artificial intelligence and natural language processing chatbots will become widely used in primary triage of spinal issues.

Совершенствование правового регулирования использования лекарственных препаратов при оказании первой помощи: проблемные и дискуссионные вопросы

Summary. Investigation purpose – based on the analysis of the range of medicines approved for medical use in the Russian Federation and their practical application in certain types of medical care, identify groups and a list of medicines for their possible use in providing first aid to victims by certain categories of first aid participants, as well as related problems requiring legislative regulation. Material and methods of the investigation. Research materials – normative legal acts reflecting the provision of first aid and medical, including emergency and primary health care, emergency and urgent care, namely: 5 federal laws; 4 Decrees of the President of the Russian Federation; 3 administrative documents of the Government of the Russian Federation; 26 administrative documents of the Ministry of Health of the Russian Federation; 1 administrative document of the Department of Health Moscow; 31 instructions for the use of medicines for medical use. Research methods: analytical, logical and information modeling. Investigation results and their analysis. Groups and a list of medicines that can be used in providing first aid to victims are proposed for consideration and discussion. Problematic issues requiring legislative regulation in the use of medicines at the stage of first aid have been identified. Groups and a list of medicines for first aid to victims are offered for consultations and discussions with representatives of scientific institutions of the medical community and government agencies that determine health policy in the Russian Federation in order to develop management decisions aimed at achieving a high level of preservation of human life and health in emergency situations.

Global Health Security in Vision Care: Health Systems Strengthening During Ebola Virus Disease Outbreak Responses.

During the last decade, global health security has been threatened by major Ebola virus disease outbreaks in Western Africa (2014 to 2016) and in eastern Democratic Republic of the Congo (2018 to 2020). Particularly in Western Africa, the outbreak initially overwhelmed health care capacity in already fragile health systems. Thousands of survivors were at risk of newly recognized postacute ocular complications, and their need for urgent ophthalmic care challenged national vision health systems with scarce eye care services. In these unprecedently large outbreaks with implications for global health security, agile eye care responses were challenging, including in regard to decision coordination and requisite logistical needs. In this report, we detail vision care initiatives implemented in response to these outbreaks and highlight the need to include vision care as a critical component of the response to infectious disease outbreaks with eye health implications.

Time to Sustained Recovery Among Outpatients With COVID-19 Receiving Montelukast vs Placebo

The effect of montelukast in reducing symptom duration among outpatients with mild to moderate COVID-19 is uncertain. To assess the effectiveness of montelukast compared with placebo in treating outpatients with mild to moderate COVID-19. This randomized clinical trial (Accelerating COVID-19 Therapeutic Interventions and Vaccines [ACTIV]-6) was conducted from January 27 through June 23, 2023, during the circulation of Omicron subvariants. Participants aged 30 years or older with confirmed SARS-CoV-2 infection and 2 or more acute COVID-19 symptoms for less than 7 days were included across 104 US sites. Participants were randomized 1:1 to receive montelukast, 10 mg once daily, or matched placebo for 14 days. The primary outcome was time to sustained recovery (defined as ≥3 consecutive days without symptoms). Secondary outcomes included time to death; time to hospitalization or death; a composite of health care utilization events (hospitalization, urgent care clinic visit, emergency department visit, or death); COVID-19 clinical progression scale score; and difference in mean time unwell. A modified intention-to-treat approach was used for the analysis. Among 1250 participants who were randomized and received the study drug or placebo, the median age was 53 years (IQR, 42-62 years), 753 (60.2%) were female, and 704 (56.3%) reported receiving 2 or more doses of a SARS-CoV-2 vaccine. Among 628 participants who received montelukast and 622 who received placebo, differences in time to sustained recovery were not observed (adjusted hazard ratio [AHR], 1.02; 95% credible interval [CrI], 0.92-1.12; P = .63 for efficacy). Unadjusted median time to sustained recovery was 10 days (95% CI, 10-11 days) in both groups. No deaths occurred, and hospitalizations were reported for 2 participants (0.3%) in each group; the composite of health care utilization events was reported for 18 participants (2.9%) in the montelukast group and 18 (2.9%) in the placebo group (AHR, 1.01; 95% CrI, 0.45-1.84; P = .48 for efficacy). Five participants (0.4%) experienced serious adverse events (3 [0.5%] in the montelukast group and 2 [0.3%] in the placebo group). In this randomized clinical trial of outpatients with mild to moderate COVID-19, treatment with montelukast did not reduce duration of COVID-19 symptoms. These findings do not support the use of montelukast for the treatment of mild to moderate COVID-19. ClinicalTrials.gov Identifier: NCT04885530.

Thirty-day healthcare encounters after elective uterine artery embolization for fibroids with and without superior hypogastric nerve block

To evaluate how the implementation of superior hypogastric nerve block (SHNB) during uterine artery embolization (UAE) for uterine fibroids impacts same-day discharge and healthcare encounters (HE) within 30 days. 240 patients who underwent successful UAE for fibroids between January 2018 and December 2022 were retrospectively reviewed. HE within 30 days, including emergency department (ED) and urgent care visits, admissions, and readmissions, were categorized as early (0-7 days of discharge) and late (8-30 days of discharge), and related or unrelated to interventional radiology (IR) care. Factors associated with same-day discharge and HE were identified with univariate analyses. Rates of HE based on SHNB status were compared using chi-square tests. Mean age was 46 ± 5 years; 125 patients received UAE with SHNB. Patients who underwent SHNB were significantly more likely to undergo same-day discharge (113/125, 90%) compared to those without SHNB (55/115, 48%) (p<0.001). There were no factors associated with rates of all-cause 30-day HE, including SHNB status (SHNB 17% (21/125) vs no SHNB 10% (12/115), p=0.20). A majority of HE were due to an IR-related cause (26/33, 79%), including abdominal or pelvic pain (22/33, 67%), nausea, vomiting, or poor oral intake (18/33, 55%), and vaginal bleeding (4/33, 12%). Comparing SHNB to no SHNB patients, there was no difference in the proportion of IR-related HE (17/21 (81%) vs 9/12 (75%), p=0.69). UAE with SHNB is associated with significantly higher rates of same-day discharge but similar rates of 30-day healthcare encounters, compared to UAE alone.

382 Testing in Urgent Care Patients With Respiratory Infections: Data From a Randomized Trial

382 Testing in Urgent Care Patients With Respiratory Infections: Data From a Randomized Trial