Emergency Department Visits Research Articles

400 Comparison of Characteristics of Pediatric Behavioral Health Emergency Department Visits, Transfers, and Admissions in California Before and During the COVID-19 Pandemic (2017-2021)

400 Comparison of Characteristics of Pediatric Behavioral Health Emergency Department Visits, Transfers, and Admissions in California Before and During the COVID-19 Pandemic (2017-2021)

Controlled Substance Use in Plastic Surgery Related Emergency Department Visits: An NEISS Study of Burn, Hand, and Face Injuries

Purpose: Psychoactive substance use is often a complicating factor in injury that requires an emergency room visit. The present study examined data recorded in the National Electronic Injury Surveillance System (NEISS) database for patients who presented to an Emergency Department (ED) and had psychoactive substance involvement, requiring management by plastic surgery. Methods: A retrospective cohort study was performed using the NEISS database, from 2019 to 2021. Data from patients aged 0 to 102 who suffered burns (46, 47, 48, 49, 51, and 73), face injuries (76), hand injuries (34, 82, and 92), and had psychoactive substance use were queried. Data regarding the specific substances involved were collected. Analysis was performed using SAS to compare the incidence of various substances and the differences in admission status with psychoactive substance use. Results: According to the NEISS estimates, in the United States, 597,916 patients visited the ED for burns, 3,671,677 for facial injuries, and 6,230,087 for hand injuries from January 2019 to December 2021. Across this population, psychoactive substance use was noted in 5605 patients with burn (0.9%), 31,198 with facial (0.8%), and 26,174 with hand (0.4%) injuries. Across all 3 injury types, the total rate of admission was 20% in the substance-use population, and 5% in the nonsubstance-use population. Conclusions: For injuries presenting to the ED that require plastic surgery management, patients with documented psychoactive substance use have higher rates of admission. Given these higher rates of admission, it is important for providers to be aware of differences in the incidences of various substances and the potential for withdrawal.

The role of 3D cinematic rendering in the evaluation of upper extremity trauma.

Traumatic upper extremity injuries are a common cause of emergency department visits, comprising between 10-30% of traumatic injury visits. Timely and accurate evaluation is important to prevent severe complications such as permanent deformities, ischemia, or even death. Computed tomography (CT) and CT angiography (CTA) are the favored non-invasive imaging techniques for assessing upper extremity trauma, playing a crucial role in both the treatment planning and decision-making processes for such injuries. In CT postprocessing, a novel 3D rendering method, cinematic rendering (CR), employs sophisticated lighting models that simulate the interaction of multiple photons with the volumetric dataset. This technique produces images with realistic shadows and improved surface detail, surpassing the capabilities of volume rendering (VR) or maximal intensity projection (MIP). Considering the benefits of CR, we demonstrate its use and ability to achieve photorealistic anatomic visualization in a series of 11 cases where patients presented with traumatic upper extremity injuries, including bone, vascular, and skin/soft tissue injuries, adding to diagnostic confidence and intervention planning.

Association Between Oral Fluoroquinolones and Neuropsychiatric Events: Self-Controlled Case Series With Active Comparator Design.

The evidence of the neuropsychiatric effects associated with fluoroquinolones is mainly supported by case reports. Population-based evidence remains largely limited. We aimed to investigate the association between the use of fluoroquinolones and hospitalization or Accident & Emergency department visits for acute neuropsychiatric events using a self-controlled case series (SCCS) and active comparator to reduce confounding. We conducted a SCCS with a recently described active comparator design using all public outpatient clinics, hospitalization, and Accident and Emergency department records from the Clinical Data Analysis and Reporting System, Hong Kong from 2001 to 2013. Among 166 325 people with an oral fluoroquinolone prescription, 4287 people who had an incident neuropsychiatric event were included. We then estimated the incidence rate ratio (IRR) of acute neuropsychiatric events during periods before and after fluoroquinolone prescription, versus baseline. We repeated the analysis for amoxicillin/clavulanic acid users as an active comparator. We then estimated the comparator-adjusted estimates by dividing the IRR for fluoroquinolone by the IRR for amoxicillin/clavulanic acid. The primary outcome was neuropsychiatric events. Secondary outcomes were psychotic events and cognitive impairment. An increased risk of neuropsychiatric events was observed in the current use of fluoroquinolone [IRR: 2.11 (95% confidence interval (CI): 1.58-2.83)] and 1-7 days after the end of fluoroquinolone prescription [IRR: 1.90 (95% CI: 1.30-2.75)] versus baseline. No increased risk was observed in other risk periods versus baseline. Similar patterns were observed in the current use of amoxicillin/clavulanic acid [IRR: 1.92 (95% CI: 1.19-3.11)] and 1-7 days after the end of fluoroquinolone prescription [IRR: 1.81 (95% CI: 1.11-2.97)] versus baseline. Similar results were found for secondary outcomes. Using the active comparator design, comparator-adjusted estimates were 1.10 (95% CI: 0.63-1.93) in current use of fluoroquinolones and 1.05 (95% CI: 0.57-1.95) in 1-7 days postexposure to fluoroquinolones versus baseline. Although our study showed a higher incidence of neuropsychiatric events in the current use of fluoroquinolones and 7 days after the end of fluoroquinolones prescriptions compared with baseline, a similar temporal pattern was also found for amoxicillin/clavulanic acid users. Using amoxicillin/clavulanic acid as the active comparator, we found no difference in the risk of neuropsychiatric events associated with fluoroquinolone compared with baseline. Therefore, the risk of neuropsychiatric events may not need to influence the decision to prescribe either fluoroquinolones or amoxicillin/clavulanic acid based on the evidence in this study.

S761 Gastroparesis is an Independent Risk Factor for Hospitalization During Emergency Department Visits for Congestive Heart Failure

S761 Gastroparesis is an Independent Risk Factor for Hospitalization During Emergency Department Visits for Congestive Heart Failure

331 Incidence and Predictors of Unplanned Return Emergency Department Visits: A Systematic Review

331 Incidence and Predictors of Unplanned Return Emergency Department Visits: A Systematic Review

256 Buprenorphine Treatment After an Emergency Department Visit for Non-Fatal Opioid Overdose

256 Buprenorphine Treatment After an Emergency Department Visit for Non-Fatal Opioid Overdose

Immunotherapy at the end of life.

188 Background: It is well established in the literature that cancer treatment administered at the end of life (EOL) does not improve either quality of life or survival rates. Patients undergoing systemic cancer treatments at near the EOL often have reduced access to hospice services and an increased likelihood of acute medical interventions, including emergency department visits, intensive care unit admissions, and in-hospital deaths. The development of immune checkpoint inhibitors (ICIs) has revolutionized cancer care over the past decade, demonstrating the ability to extend progression-free survival and overall survival in patients with various cancers. Furthermore, ICIs may represent a promising therapeutic option for adults with impaired performance status (PS) due to their relatively favorable side-effect profile when compared to conventional chemotherapy. While numerous studies have examined chemotherapy at the end of life, research specifically focusing on the administration of immunotherapy during this period is scarce. Methods: We conducted a retrospective chart review using the electronic medical record database at Scripps clinic focusing on cancer patients undergoing immunotherapy who passed away between June 1, 2017, and August 30, 2023, comprising a cohort of 641 individuals. Our investigation was designed to provide a retrospective overview of patient characteristics and outcomes, with a specific emphasis on factors at EOL. Results: The most prevalent tumor types were lung (34%), GI (21%), skin (13%), GU (12.6%) and others (19.4%). On average, no patients received immunotherapy in the last 30 days of their lives. Among the different cancer types, breast cancer patients had the longest interval between last treatment and death, averaging 259 days. This was followed by patients with head and neck cancer (207 days), skin cancer (199 days), genitourinary (GU) cancers (177 days), lung cancer (140 days), gynecological (GYN) cancers (135 days), and gastrointestinal (GI) cancers (134 days). 19 patients died from immune-related adverse events (IrAEs). These patients had the shortest interval between their last treatment and death, with a mean of 34 days. This was followed by those who died due to cancer progression, with an average interval of 148 days. Conclusions: The decision to administer anticancer therapies near the EOL is increasingly complex. Oncologists must carefully discuss immunotherapy with patients, monitor for IrAEs, and consider discontinuing treatment if there is disease progression, worsening PS or after two years of treatment.

196 COVID-19 Pandemic-Related Racial/Ethnic Disparities in Emergency Department Visits for Patients With Childhood Asthma in the United States

196 COVID-19 Pandemic-Related Racial/Ethnic Disparities in Emergency Department Visits for Patients With Childhood Asthma in the United States

137 Pediatric Telemedicine Care Is Associated With Minimal Increases in Subsequent Emergency Department Visits

137 Pediatric Telemedicine Care Is Associated With Minimal Increases in Subsequent Emergency Department Visits

438 Identifying and Addressing Health Care Barriers for Frequent Emergency Department Visitors

438 Identifying and Addressing Health Care Barriers for Frequent Emergency Department Visitors

Association between Unmet Social Need and Ambulatory Quality of Care for U.S. Children

ObjectivesChildren who experience socioeconomic adversity often have worse health; however, less is known about their quality of care. We sought to evaluate the association between parent/caregiver-reported socioeconomic adversity and quality of pediatric primary, acute, and chronic ambulatory care on a national level. MethodsThis was a retrospective cohort study of 5,368 representative U.S. children (1-17 years) in the 2021 Medical Expenditure Panel Survey. Socioeconomic adversity was defined as parent/caregiver-reported food, housing, transportation, or utility insecurity in the past 12 months. Outcomes included 10 quality measures of primary, acute, and chronic care, and experience of care measured through parent/caregiver survey. We described variation in socioeconomic adversity and used multivariable regression to examine associations with quality outcomes. ResultsOne-third of parent/caregivers reported socioeconomic adversity. Food insecurity (23.6%) was most common followed by utility (19.5%), housing (15.0%), and transportation (4.7%) insecurity. Black (53.2%) and Hispanic (46.9%) parent/caregivers experienced the highest rates of socioeconomic adversity. Children with socioeconomic adversity received lower quality of care for 4 quality measures, including more frequent ED visits (Odds Ratio (OR)=1.69 [95% Confidence Interval (CI):1.28-2.23]), less favorable asthma medication ratio (OR=0.04 [95%CI:0.01-0.31]), and less frequent well child (OR=0.73 [95%CI:0.59-0.90]) and dental care (OR=0.76 [95%CI:0.63-0.94], p <.05 for all). There were no statistically significant differences in experience of care. ConclusionsSocioeconomic adversity is common among U.S children with disproportionate impact on Black and Hispanic families. There are significant disparities in pediatric primary, acute, and chronic care quality, based on parent/caregiver-reported socioeconomic adversity, highlighting the need for systems-level interventions.

Epidemiology of heart failure presentations to United States emergency departments from 2016 to 2023

IntroductionHeart failure (HF) is a common condition prompting presentation to the Emergency Department (ED) and is associated with significant morbidity and mortality. However, there is limited recent large-scale, robust data available on the admission rates, evaluation, and treatment of HF in the ED setting. MethodsThis was a cross-sectional study of ED presentations for HF from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits with ICD-10 codes corresponding to acute HF were included. We excluded congenital heart disease and isolated right-sided HF. Outcomes included percentage of total ED visits, admission rates, troponin, B-type natriuretic peptide (BNP), chest radiography, and diuretic and nitroglycerin medication administration. Subgroup analyses of medications were performed by medication and route of administration (transdermal, sublingual/oral, and intravenous). ResultsOut of 190,694,752 ED encounters, 2,626,011 (1.4 %) visits were due to acute HF. Of these, 1,897,369 (72.3 %) were admitted to the hospital. The majority of patients had a troponin (90.3 %), BNP (91.1 %), and chest radiograph (89.5 %) ordered. 82.5 % received intravenous diuresis, while 46.2 % received oral diuresis. The most common diuretic was furosemide (78.4 % intravenous, 32.5 % oral), followed by bumetanide (9.5 % intravenous, 7.1 % oral), and torsemide (0 % intravenous, 8.1 % oral). Nitroglycerin was given in 26.0 %, with the most common route being sublingual/oral (16.6 %), followed by transdermal (9.2 %) and intravenous (3.5 %). ConclusionHF represents a common reason for ED presentation, with the majority of patients being admitted. All patients received diuresis in the ED, with the majority receiving intravenous diuresis with furosemide. Approximately one-quarter received nitroglycerin with the sublingual/oral route being most common. These findings can help inform health policy initiatives, including admission decisions and evidence-based medication administration.

Risk of Dementia Diagnosis After Injurious Falls in Older Adults

Emerging evidence suggests that mild cognitive impairment, which is a precursor to Alzheimer disease and related dementias (ADRD), places older adults at increased risk for falls. However, the risk that an older adult develops dementia after experiencing a fall is unknown. To determine the risk of new ADRD diagnosis after a fall in older adults. This retrospective cohort study examined Medicare Fee-for-Service data from 2014 to 2015, with follow-up data available for at least 1 year after the index encounter. Participants included adults aged 66 years and older who experienced a traumatic injury that resulted in an emergency department (ED) or inpatient encounter and did not have a preexisting diagnosis of dementia. Data analysis was performed from August 2023 to July 2024. Experiencing a fall compared with other mechanisms of injury, defined by International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 external cause of injury codes. The hazard of new ADRD diagnosis within 1 year of a fall, assessed by performing a Cox multivariable competing risk model that controlled for potential confounders while accounting for the competing risk of death. The study included 2 453 655 older adult patients who experienced a traumatic injury; 1 522 656 (62.1%) were female; 124 396 (5.1%) were Black and 2 232 102 (91.0%) were White; and the mean (SD) age was 78.1 (8.1) years. The mechanism of injury was a fall in 1 228 847 incidents (50.1%). ADRD was more frequently diagnosed within 1 year of a fall compared with other injury mechanisms (10.6% [129 910 of 1 228 847] vs 6.1% [74 799 of 1 224 808]; P < .001). The unadjusted hazard ratio (HR) of incident dementia diagnosis after a fall was 1.63 (95% CI, 1.61-1.64; P < .001). On multivariable Cox competing risk analysis, falling was independently associated with an increased risk of dementia diagnosis among older adults (HR, 1.21 [95% CI, 1.20-1.21]; P < .001) after controlling for patient demographics, medical comorbidities, and injury characteristics, while accounting for the competing risk of death. Among the subset of older adults without a recent skilled nursing facility admission, the HR was 1.27 (95% CI, 1.26-1.28; P < .001). In this cohort study, new ADRD diagnoses were more common after falls compared with other mechanisms of injury, with 10.6% of older adults being diagnosed with ADRD in the first year after a fall. To improve the early identification of ADRD, this study's findings suggest support for the implementation of cognitive screening in older adults who experience an injurious fall that results in an ED visit or hospital admission.

Using Oncology Treatment Pathway Data to Evaluate Serious Illness Communication, Care Utilization, and End-of-Life Care for Patients With Cancer.

Oncology treatment pathways provide decision support and encourage guideline adherence. Pathway data combined with electronic health record (EHR) data can identify patient populations with poor prognoses, low serious illness conversation (SIC) rates, and high acute care utilization that may benefit from targeted interventions. We conducted a retrospective cohort analysis among adults with cancer treated at seven affiliated sites of the Dana-Farber Cancer Institute (DFCI) who had navigations within 21 treatment pathways between July 29, 2019, and March 8, 2023. DFCI clinicians previously identified pathway nodes with an estimated survival less than 1 year, termed poor prognosis (PP) nodes. We combined pathway data with EHR data to calculate the median overall survival (OS) and proportion of patients with SICs, acute care utilization (hospitalizations and emergency department visits), and outpatient palliative care 6 months after treatment node navigation for all, PP, and nonpoor prognosis (nPP) nodes. SICs were identified using the EHR advanced care planning (ACP) tab. There were 15,261 navigations for 10,203 patients (median age 66 years, 55% female, 85% White). The median OS was 13.8 months for all nodes, 7.8 months for PP nodes, and 21.0 months for nPP nodes. The ACP section of the EHR rate 6 months after navigation was 19.6% for PP nodes versus 11.0% for nPP nodes. There was substantial intragroup variability in OS and SIC rates among all nodes. SICs were recorded in the ACP tab for only 34.3% of decedents. Patients who navigated to PP nodes had higher levels of acute care utilization and palliative care encounters. Treatment pathway data enabled identification of patient populations with poor prognoses, low SIC rates, and high acute care utilization.

Health impacts of excessive heat in Multnomah County, OR, 2021

Abstract Human-induced climate change is leading to increased extreme weather events, such as the heat dome that occurred in Multnomah County, OR, in June 2021. Certain groups are at increased risk from excessive heat events, such as the very young and very old, persons without stable housing, and persons with certain health comorbidities. Our review of three data sources (deaths, hospitalizations, and emergency department visits) showed large increases in all three measures in the summer of 2021. Further, two-thirds of identified heat deaths occurred in or near neighborhoods that ranked among the most vulnerable to extreme heat. Despite thoughtful planning, a recently updated heat response plan, and an unprecedented mobilization of resources, we documented severe health impacts due to this heat event. We recommend that local health jurisdictions and emergency responders increase readiness for such events by interrogating existing plans and tailoring them not to events of expected severity, but to a worst case scenario that exceeds historic experiences.

Adult Food Poisoning in a Tertiary University Hospital: Retrospective Evaluation of Emergency Department Visits and Outcomes

Aim The clinical diagnosis, which occurs with various symptoms as a result of consumption of contaminated food, is defined as food poisoning (FP). A large number of people experience FP around the world each year. This report focuses on the clinical and descriptive characteristics of adult cases visiting the emergency department (ED) due to FP. Material and Methods This study was planned as a retrospective examination of adult FP cases who visited a tertiary ED in a 4-year period. Complaints, vital signs, physical examination and laboratory data at the time of the visit were recorded. The treatment given for ED and the ways to recover from ED were also evaluated. Results 61 patients were included. 43 patients (70.5%) were male. Median age was 31 years (min: 18- max: 73). The most common symptom was nausea (n=27, 44.3%). No relationship was detected between length of hospital stay and descriptive data. Most of cases except two (96.7%), were discharged after the treatments administered in the ED. Conclusion FP cases are often young and male. They most often visit ED with complaints of nausea and are often discharged from ED after treatment. Descriptive data is not predictive of outcomes.

Povezanost med vročinskimi valovi in obiski na Internistični prvi pomoči Univerzitetnega kliničnega centra Ljubljana v obdobju 2013–2017

Background: Heatwaves have a severe impact on the number of deaths and emergency department visits, making them the most hazardous natural disaster due to climate change in many regions of the world. Our aim was to assess the short-term association between emergency department visits and heat waves from 2013 to 2017 to see whether any difference in the number of visits occurred at the Emergency Department in Ljubljana University Medical Centre during that period. Methods: The design of our study is a retrospective cross-sectional epidemiologic study. We estimated relative risks (RR) for a number of ED visits during heatwave days and reference period days for the observed diagnoses (all causes, diseases of the circulatory system, respiratory system, endocrine diseases, diseases of the digestive system and genitourinary diseases) sex, and age (from 19 to 74 years old, 75 years old and older), as well as 99.6% confidence intervals (CI) and excess ED visits in percent (%) associated with heatwaves occurring in the years from 2014 to 2017. Data were analyzed for the patients arriving at the Emergency Department of the Ljubljana University Medical Centre during summer time, from May to September. The region covers around 550,000 people and is considered an urban and rural area. Results: The results of our study showed that there was no statistically significant increase in number of ED visits during heatwaves for all causes in all observed years. We noticed even statistically significant protective phenomena between heatwaves and the number of ED visits. These happened in the years 2015 and 2017 for both sexes and circulatory system diseases, in 2016 for men, circulatory system diseases, and in 2015 for respiratory system diseases. We showed a statistically significant association between heatwaves and the number of visits in the ED for endocrine diseases in 2013. Conclusion: Despite the increased heat load in the last observed years, the number of ED visits in Ljubljana has remained stable or even decreased. Further studies on how each intervention affects the behavior of the observed population are needed to clarify whether public health measures and inter-sectoral cooperation impact the number of ED visits.

Systematic Review and Meta-Analysis of Diagnostic and Predictive Accuracy of the Clinical Frailty Scale in Older Adults in Emergency Department

Abstract Background Older adults attending the Emergency Department (ED) should be assessed using a frailty screening tool as older adults living with frailty are more likely to experience adverse outcomes. The Clinical Frailty Scale (CFS) is commonly used for this. This systematic review and meta-analysis synthesise the literature studying predictive accuracy of the CFS for identifying older adults at risk of adverse outcomes following ED visit, and the diagnostic accuracy of the CFS for identifying older adults living with frailty attending the ED. Methods A systematic literature search was conducted to identify studies that attempted to validate the diagnostic and predictive accuracy of the CFS for older adults in the ED setting. The population included were older adults over 65 years of age who presented to the ED with undifferentiated medical complaints. All included studies assessed the diagnostic accuracy of the CFS in comparison to a reference standard: Frailty Index, Comprehensive Geriatric Assessment or Frailty Phenotype. The adverse outcomes included were mortality, falls, functional decline, ED re-attendance, hospital admission, length of stay and institutionalisation. Results Nineteen studies were included with sixteen individual cohorts. All studies investigated predictive accuracy and four studies assessed diagnostic accuracy for the CFS. The CFS showed predictive accuracy for the outcomes of mortality at all timepoints (RR 3.05 (CI 2.22, 4.21)), ED re-attendance at 30 days (RR 1.47 (CI 1.12, 1.94)), hospital admission at index visit (RR 1.72 (CI 1.26, 2.34) and institutionalisation (RR 3.63 (CI 1.41, 9.36). The studies included had an overall low risk of bias. Conclusion The CFS successfully identifies those at risk of adverse outcomes of death, ED revisit, hospitalisation and institutionalisation. However, there is a paucity of studies which assess its diagnostic accuracy. Overall, it is a useful screening tool to identify those who may benefit from comprehensive multidisciplinary assessment in the ED setting.

Unexpected Journeys: Investigating Urgent and Emergency Care Trends of Patients Attending a Community Specialist Team for Older Adults

Abstract Background Transitions of care for older people via ICPOP and Urgent and Emergency Care (UEC) pathways are becoming more complex. Demand for unscheduled care for older adults with complex care needs will increase with an ageing society, requiring proactive case management and practical realisation of integrated care pathways. Methods Retrospective analysis of UEC presentations of older patients attending a community specialist team (CST) who underwent Comprehensive Geriatric Assessment (CGA) between January-July 2023. Demographics and functional status [Clinical Frailty Score (CFS), Barthel Index (BI), Lawton-Brody Score (IADL), Montreal Cognitive Assessment (MOCA)] were extracted, along with UEC presentations post-CGA until March 2024. Results 356 patients underwent CGA and 42% (n=148) had subsequent unscheduled care attendance(s). Of those with an UEC attendance 36% (n=54) lived alone. Median functional scores were: CFS 5, BI 17, IADL 3, MOCA 17. Median time to UEC presentation was 100 days since CGA. There were 283 UEC interactions in total. 39% (n=58) had &amp;gt;1 interaction. 73% (n=206) of interactions resulted in acute hospital admissions, 21% (n=58) were ED visits, and 6% (n=19) were Pathfinder interactions. Falls (31%) and infection (19%) were the leading causes for presentation. Of 206 admissions, 61% were admitted under medical specialties, 26% under Geriatric Medicine, and 13% under Surgery. Average hospital stay was 13 days. 65% (n=134), were discharged home, 11% (n=22) to transitional care beds, 7% (n=15) to rehabilitation, 7% (n=14) to nursing home, 3% (n=5) transferred to other hospitals, 7%(n=15) died. Conclusion Over half of patients attending a CST had an UEC presentation, reflecting the complexity of this cohort and their level of healthcare utilisation. Case management roles that complement and pull together existing elements of the older persons pathway are lacking across healthcare settings and are fundamental to successful implementation of a patient-centred age friendly health system.