Emergency Department Visits Research Articles

Long term care-acute system integration and transformation: Innovations in models of care.

The article discusses innovations in integrating Long-Term Care (LTC) and acute systems, focusing on Humber River Health's (HRH) model. Older adults in LTC homes are vulnerable to avoidable Emergency Department (ED) visits due to frailty and medical complexity. HRH developed an integrated care model centred on LTC Remote Monitoring (RM) with LTC partners, leveraging nurse-led care models, digital tools, and virtual care hub to reduce avoidable ED transfers. Key components include the PREVIEW-ED© tool for early detection of clinical deterioration, LTC+ Hub and LTC++ Diagnostic Imaging and Transportation, supporting improved access to healthcare services. The program aligns with the Quintuple Aim, emphasizing patient and provider experiences, population health, cost reduction, and health equity. Results show significant reductions in ED visits, hospital lengths of stay, and associated costs, while enhancing resident and provider experiences. The LTC RM model is positioned as a scalable solution for system transformation in integrated care.

Evaluation and Revision of Historical ESSENCE Syndromic Surveillance Definition Used to Identify Work-Related Emergency Department Visits.

Occupational health surveillance programs have rarely incorporated syndromic surveillance. We documented a process for evaluating and revising syndromic surveillance definitions, using the example of work-related emergency department (ED) visits. Of 140 331 481 ED visits in the National Syndromic Surveillance Program from May 15, 2016, through October 31, 2017, we extracted 391 827 records for phase 1 that met the previously unevaluated original work-related definition or included a work-related employment status ICD-10-CM code (Y99.0/Y99.1; International Classification of Diseases, Tenth Revision, Clinical Modification). Also for phase 1, we evaluated the performance of the original work-related definition using ICD-10-CM work-related employment status codes as a reference standard. In phase 2, we extracted 99 109 records containing candidate work-related keywords. Finally, in phase 3, we examined individual keywords and developed and evaluated a revised definition. The revised work-related definition identified 259 153 visits by keyword alone, 104 342 visits by ICD-10-CM work-related employment status codes alone, and 16 385 ED visits by both methods. Sensitivity (13.6% vs 11.3%) and positive predictive value (5.9% vs 4.8%) were higher for the revised definition than for the original work-related definition. Manual review indicated that 91.3% (95% CI, 89.6%-93.0%) of visits identified by the revised definition keywords met the study criteria for work-related visits as compared with 75.5% (95% CI, 73.0%-78.4%) of visits for the original work-related definition. The original work-related definition performed suboptimally because keywords were not sufficiently specific. The revised definition is an improvement but requires testing in real-world scenarios. The presented methods for developing a syndromic surveillance definition are useful, not only for occupational health, but for identification of other subpopulations treated in the ED.

Machine Learning For Risk Prediction After Heart Failure Emergency Department Visit or Hospital Admission Using Administrative Health Data.

Patients visiting the emergency department (ED) or hospitalized for heart failure (HF) are at increased risk for subsequent adverse outcomes, however effective risk stratification remains challenging. We utilized a machine-learning (ML)-based approach to identify HF patients at risk of adverse outcomes after an ED visit or hospitalization using a large regional administrative healthcare data system. Patients visiting the ED or hospitalized with HF between 2002-2016 in Alberta, Canada were included. Outcomes of interest were 30-day and 1-year HF-related ED visits, HF hospital readmission or all-cause mortality. We applied a feature extraction method using deep feature synthesis from multiple sources of health data and compared performance of a gradient boosting algorithm (CatBoost) with logistic regression modelling. The area under receiver operating characteristic curve (AUC-ROC) was used to assess model performance. We included 50,630 patients with 93,552 HF ED visits/hospitalizations. At 30-day follow-up in the holdout validation cohort, the AUC-ROC for the combined endpoint of HF ED visit, HF hospital readmission or death for the Catboost and logistic regression models was 74.16 (73.18-75.11) versus 62.25 (61.25-63.18), respectively. At 1-year follow-up corresponding values were 76.80 (76.1-77.47) versus 69.52 (68.77-70.26), respectively. AUC-ROC values for the endpoint of all-cause death alone at 30-days and 1-year follow-up were 83.21 (81.83-84.41) versus 69.53 (67.98-71.18), and 85.73 (85.14-86.29) versus 69.40 (68.57-70.26), for the CatBoost and logistic regression models, respectively. ML-based modelling with deep feature synthesis provided superior risk stratification for HF patients at 30-days and 1-year follow-up after an ED visit or hospitalization using data from a large administrative regional healthcare system.

Impact of marginalization on characteristics and healthcare utilization among people with substance use disorder in Ontario, Canada, before and during the COVID-19 pandemic: A cross-sectional study.

To describe and compare the characteristics of people with SUD and their use of healthcare services in two ways: 1) across varying levels of marginalization and 2) before and during the pandemic. We conducted a population-based cross-sectional study using administrative data from Ontario, Canada. We included individuals age 16+ with a recorded diagnosis of SUD between June 2018-2019 (pre-pandemic) and June 2021-2022 (during-pandemic). Baseline sociodemographic and clinical characteristics and use of healthcare services were enumerated across the five quintiles of the Ontario Marginalization Index. 259,497 pre-pandemic and 276,459 during-pandemic people with SUD were identified. Over 40% belonged to the two highest marginalization quintiles (Q4/Q5). Most had an outpatient visit with similar percentages across quintiles, however the number of visits increased with increasing marginalization (pre-pandemic: mean 8.5 visits in Q1 vs 13.0 visits in Q5; during-pandemic: mean 9.5 in Q1 vs 13.4 in Q5). There was no consistent pattern in percent of people who sought alcohol-related outpatient care, however more marginalized people sought drug-related outpatient care (pre-pandemic: 19.1% in Q1 vs 31.7% in Q5; during-pandemic: 18.7% in Q1 vs 32.5% in Q5). Almost half of people with SUD had an emergency department (ED) visit, of which more belonged to higher marginalization quintiles (pre-pandemic: 43.5% in Q1 vs 49.8% in Q5; during-pandemic: 41.4% in Q1 vs 49.3% in Q5). SUD prevalence and most health service utilization remained similar from pre- to during-pandemic. Increasing marginalization was associated with increased use of healthcare among people with SUD. Future research should aim to further explore the complex relationship between marginalization and substance use.

Early prediction of sepsis in emergency department patients using various methods and scoring systems.

Early recognition of sepsis, a common life-threatening condition in intensive care units (ICUs), is beneficial for improving patient outcomes. However, most sepsis prediction models were trained and assessed in the ICU, which might not apply to emergency department (ED) settings. To establish an early predictive model based on basic but essential information collected upon ED presentation for the follow-up diagnosis of sepsis observed in the ICU. This study developed and validated a reliable model of sepsis prediction among ED patients by comparing 10 different methods based on retrospective electronic health record data from the MIMIC-IV database. In-ICU sepsis was identified as the primary outcome. The potential predictors encompassed baseline demographics, vital signs, pain scale, chief complaints and Emergency Severity Index (ESI). 80% and 20% of the total of 425 737 ED visit records were randomly selected for the train set and the test set for model development and validation, respectively. Among the methods evaluated, XGBoost demonstrated an optimal predictive performance with an area under the curve (AUC) of 0.90 (95% CI: 0.90-0.91). Logistic regression exhibited a comparable predictive ability to XGBoost, with an AUC of 0.89 (95% CI: 0.89-0.90), along with a sensitivity and specificity of 85% (95% CI: 0.83-0.86) and 78% (95% CI: 0.77-0.80), respectively. Neither of the five commonly used severity scoring systems demonstrated satisfactory performance for sepsis prediction. The predictive ability of using ESI as the sole predictor (AUC: 0.79, 95% CI: 0.78-0.80) was also inferior to the model integrating ESI and other basic information. The use of ESI combined with basic clinical information upon ED presentation accurately predicted sepsis among ED patients, strengthening its application in ED. The proposed model may assist nurses in risk stratification management and prioritize interventions for potential sepsis patients, even in low-resource settings.

The use and impact of pathology tests in emergency department patients with mental health-related complaints: A cross sectional study.

To evaluate the use and impact of pathology tests in patients who present to the ED with mental health-related complaints. The primary objective is to measure the proportion of patients undergoing pathology tests and assess whether these tests trigger a change in management. In this retrospective study, we reviewed all recorded mental health presentations to our regional ED between January and June 2021. Patient characteristics, pathology tests, subsequent change in management, treatment costs and time to Emergency Physician and Psychiatrist were extracted. Descriptive statistics and multivariate analysis were used to explore associations between variables of interest, ED length of stay (LOS) and change in management. Of 37 900 ED visits, 1462 (3.9%) were mental health-related presentations. Pathology tests were conducted in 47.7% of cases, with 3% leading to a change in management. Pathology tests were associated with increased treatment costs (45% increase for blood tests, 17% for urine), and increased ED LOS (48%). Patients with coexisting medical conditions were three times more likely to have a change in management. Pathology tests should be reserved for patients with high-risk features and based on clinical assessment. Strategic use of pathology tests could avoid unnecessary delays and costs, enhancing patient care in mental health-related ED presentations.

Safety and adherence of early oral immunotherapy for peanut allergy in a primary care setting: a retrospective cross-sectional study

BackgroundPeanut allergy is a common food allergy with potentially life-threatening implications. Early oral immunotherapy for peanut allergy (P-EOIT) has been shown to be effective and safe in research and specialty clinic settings. Provision of P-EOIT in primary care would make it available to more patients. We sought to assess the safety of P-EOIT in a primary care setting by documenting the rates of peanut-related allergic reactions leading to emergency department (ED) visits and use of epinephrine. We also examined adherence by assessing the percentage of patients reaching maintenance phase and continuing ingestion after one year of P-EOIT.MethodsThis retrospective study included all patients aged less than 36 months who started P-EOIT at a primary care allergy clinic in New Brunswick, Canada, from 2016 to 2020. The population included patients who (1) had a history of an allergic reaction to peanuts with a positive skin prick test or positive peanut specific IgE level (ps-IgE) or (2) no history of ingestion and a baseline ps-IgE ≥5 kU/L. Patients had biweekly clinic visits with graded increases in peanut protein up to a maintenance dose of 300 mg of peanut protein daily. A blinded retrospective review of paper charts and electronic medical records was conducted along with phone interviews regarding ED visits and epinephrine use.ResultsAll 69 consented patients reached maintenance dose over a median of 29 weeks, and 66 patients (95.7%) were still regularly consuming peanut protein after 1 year of maintenance. One patient had a peanut ingestion-related ED visit requiring epinephrine during the escalation phase of peanut protein dosing (1.4%). During the first year of maintenance phase, no patients had peanut ingestion-related ED visits nor required epinephrine.ConclusionEarly oral immunotherapy for peanut allergy in a primary care setting appears to be safe and our findings suggest that it does not lead to an increased burden of emergency department visits. Our population had high adherence rates, with the majority achieving maintenance dose and staying on this dose for one year.

Risk factors for acute appendicitis among adult patients with indeterminate ultrasound.

Abdominal ultrasound is used for diagnosing appendicitis in patients with right lower quadrant abdominal pain. Between 45 and 82% of radiology performed ultrasounds are indeterminate for appendicitis and computed tomography is required for diagnostic confirmation. Our study aims to determine predictors to rule out appendicitis when ultrasound is indeterminate. We performed a health records review of adult emergency department (ED) patients presenting with symptoms suspicious for appendicitis and indeterminate ultrasound to two academic EDs between June 2019 and July 2020. The outcome was appendicitis diagnosis within 30days of the index ED visit. We used multivariable logistic regression, identifying a cut-off threshold for continuous variables with cubic spline, and chose the parsimonious model to develop a binary decision rule. We report Odds ratios (OR) and diagnostic performance with 95% confidence intervals (CI). Overall, 463 patients (mean age 30.3years (SD 10.5years), 74.9% female) were included. Appendicitis was diagnosed in 45 patients (9.7% [95% CI 7.2-12.8%]). After ultrasound, computed tomography was performed in 227 patients (49.0%) and 39 patients (17.2%) were diagnosed with appendicitis. Among the 236 patients who did not have a subsequent computed tomography, 6 (2.6%) patients had appendicitis. Neutrophil count > 5.5 × 109/L (OR 1.21 [95% CI 1.12-1.30]) and secondary signs of inflammation on ultrasound (OR 2.16 [1.07-4.37]) were associated with a higher likelihood of appendicitis (C-statistic 0.77 [95% CI 0.70-0.84]). The absence of both predictors had a sensitivity of 88.9% (95% CI 76.0-96.3%), specificity of 45.7% (95% CI 40.8-50.6%) and a negative predictive value of 0.97 (95% CI 0.94-0.99) to rule out appendicitis. For patients suspected of appendicitis and indeterminate ultrasound, the absence of an elevated neutrophil count and secondary signs of inflammation are associated with a low probability of appendicitis.

Gather "Round": An Integrated Care Model for the Emergency Department Multi-Visit Patient.

Emergency departments (EDs) are a vital component of the United States healthcare system and care for over 130 million patient visits annually. Nonurgent ED visits can contribute to crowding, delays in care, and adverse effects. Many high-utilizing ED patients may present with complex medical, behavioral, and social needs that are not necessarily emergent or urgent in nature. The authors created an Integrated Care Model, called the Multi-Visit Patient (MVP) program, for patients with 5 or more visits to the ED in a rolling 12-month period. The MVP program incorporated an interdisciplinary group of ED leadership and case management (CM) to identify, engage, and intervene with ED MVPs, aiming to improve their ED utilization. Patients received comprehensive screenings for depression, falls, alcohol use disorder, caregiver support, social determinants of health, and more. Based on these screenings, the CM team implemented interventions such as connecting patients with outpatient specialists and linking patients to community-based organizations to optimize stability, wellness, and reduce ED utilization. The collaboratively developed MVP program was implemented in the ED of a large, suburban, tertiary care academic hospital. The MVP program identified 221 MVP patients over a 20-month period and successfully connected with 89% of them. Of these 221 patients, 78% (172 patients) chose to engage in the MVP program, with 160 completing their engagement with an outcome. Among the patients who completed their engagement and for whom the study could match separate utilization data (151 patients), the study observed a 57% reduction in ED visits. Case managers play a crucial role in the effectiveness of the MVP program by coordinating comprehensive care for high-utilizing ED patients. The MVP program includes transition of care initiatives designed to improve patient outcomes. Through screenings and targeted interventions, case managers identify and address the complex medical, behavioral, and social needs of MVP patients. This collaborative, interdisciplinary approach underscores the importance of timely and coordinated care, benefiting both patients and the health system. The MVP program exemplifies the critical role of case managers in reducing unnecessary ED visits and enhancing overall patient care.

Clinical, Quality of Life, and Health Care Utilization Outcomes of Switching the Administration Route of Antipsychotic Medications Among People With Schizophrenia Spectrum Disorder: A Systematic Review and Meta-Analysis.

Using long-acting injectable (LAI) antipsychotic medications can improve the outcomes of patients with schizophrenia, such as reducing symptom severity and hospitalization risk. However, the outcomes of switching from oral to LAI antipsychotic medications are unclear. The purpose of this review is to provide a summary of the clinical, quality of life, and health care utilization outcomes of switching from oral to LAI antipsychotics among patients with Schizophrenia Spectrum Disorder. We thoroughly searched the PubMed, Scopus, PsycInfo, and CINAHL databases. To conduct the meta-analysis, we used the Comprehensive Meta-Analysis Program. Forty-one articles met our inclusion criteria. After switching to LAIs, symptom severity, the number of rehospitalizations, emergency department visits, and overall health care costs were reduced. Also, social functioning significantly improved. However, no differences were observed in the frequency of outpatient visits. Pharmacy costs were increased between pre- and post-LAI initiation. Our findings support evidence that changing the route of administration of antipsychotic medications from oral to long-acting intramuscular injections can improve the clinical, quality of life, and health care utilization outcomes in people with schizophrenia. Health care practitioners might consider encouraging LAI use earlier during treatment for schizophrenia for better clinical outcomes and to reduce health care utilization associated with treatment.

15 Predictive validity of two developmental screening tools at the 18-month visit and neurodevelopmental consultation at an average age of 8 years

Abstract Background The Canadian Paediatric Society (CPS) recommends an enhanced 18-month well-baby visit incorporating a developmental screening tool to stimulate discussion with parents, and notes that a widely used tool is the Nipissing District Developmental Screen (NDDS). For early detection of autism spectrum disorder, the CPS notes that a commonly used screening tool is the Infant Toddler Checklist (ITC). Objectives To examine the predictive validity of the ITC and NDDS at the 18-month visit using later neurodevelopmental consultation as the criterion measure; and examine whether positive developmental screening was associated with health care utilization (HCU). Design/Methods Using a prospective design, parents completed the ITC and the NDDS at the 18-month visit in primary care practices. Seven types of HCU were collected from health administrative databases, via linkage using the child’s health insurance number, including: neurodevelopmental consultation, special paediatric consultation, scheduled primary care visit billings, unscheduled primary care or minor visit billings, other non-primary care visit billings, hospitalizations, and emergency department visits. Covariates included child and family characteristics. We calculated screening test properties (using neurodevelopmental consultation as the criterion) and used multivariable negative binomial regression to estimate rate ratios (RR) for each of the 7 types of HCU. Results For both the ITC (n=1460) and NDDS (n=802) cohorts, mean age at screening was 18 months and mean age at follow up was 8 years. Of the ITC cohort, 11% were screen positive, 2.6% had a neurodevelopmental consultation. A positive ITC had 40% sensitivity (95% CI 24%-57%), 90% specificity (95% CI 88%-91%), 10% false positive rate (95% CI 9%-12%). A positive ITC was associated with 6 of 7 types of HCU, including neurodevelopmental consultation (RR=2.78, 95% CI 1.37-5.67). Of the NDDS cohort, 36% were screen positive, 2.5% had a neurodevelopmental consultation. A positive NDDS had a sensitivity of 50% (95% CI 27%-73%), specificity of 65% (95% CI 61%-68%), false positive rate of 35% (95% CI 31%-40%). A positive NDDS was associated with only 1 of 7 types of HCU: unscheduled primary care or minor visit billings 1.24 (95% CI 1.01, 1.53, p=0.04). Conclusion The predictive validity of the ITC was stronger than the NDDS due to high specificity and low false positive rates. The low sensitivity of the ITC is similar to other screening tools used at 18 months, highlighting the importance of ongoing developmental surveillance. The false positive rate of the NDDS is unacceptably high for a screening tool.

36 The long-term consequences of short-course systemic corticosteroid therapy for childhood acute asthma exacerbations

Abstract Background Paediatric emergency department (ED) asthma guidelines recommend the administration of short-course systemic corticosteroids (SCS) for moderate to severe asthma exacerbations. The potential adverse implications of frequent, short-course SCS in children are poorly characterized. Objectives To determine the risk of adverse outcomes in children with asthma who receive multiple short-courses of SCS for asthma exacerbation management. Design/Methods In this population-based, retrospective cohort study, we identified children aged 1-16 years with an ED asthma presentation/hospitalization between October 1, 2017, and February 28, 2020. We divided participants into an SCS-exposed and unexposed cohort. A minimum washout period of 3 years was applied to exclude any SCS use before the index date. During a 24-month follow-up period, we captured cumulative short-courses of SCS for acute asthma management and the primary outcome, development of steroid-associated complications. We excluded participants with steroid-treated comorbidities, non-asthma-related SCS exposure and development of adverse outcome(s) before the index visit. We compared baseline characteristics between cohorts using descriptive statistics. A Prentice-Williams-Peterson model was used to determine the risk of adverse outcomes amongst children receiving SCS for asthma management with results expressed as adjusted hazard ratios (HR) and 95% Wald confidence intervals (CI). Results We identified 1468 participants with an asthma ED visit who received ≥1 SCS course for acute management and 541 participants who did not receive SCS during our study window, after applying inclusion/exclusion criteria. Baseline demographics were balanced between cohorts aside from age at index, which was significantly younger (4.31 ± 3.71 vs 7.64 ± 4.21 p<0.001) in the SCS-exposed cohort. Overall, the risk of developing a recurrent SCS-associated adverse outcome was not increased in the SCS-exposed cohort (HR = 0.95, 95% CI: 0.74-1.23, p=0.7). However, when the number of SCS courses was considered, a significant risk of recurrent SCS-associated outcomes emerged, especially for those receiving 4+ SCS courses (HR = 2.30, 95% CI: 0.92-5.80). This potential dose-response effect was negated when patients who were likely on medium to high dose maintenance inhaled corticosteroids, were removed in a sensitivity analysis (HR = 1.38, 95% CI: 0.35-5.39). Conclusion At a tertiary care Canadian paediatric hospital, children and adolescents receiving short-course SCS for asthma exacerbation management overall do not demonstrate an increased risk of developing complications after two years follow-up. However, complication risk may be increased among those receiving 4+ cumulative SCS courses.

33 Use of CHU Ste. Justine online resources prior to visiting the Emergency Department for less-urgent, acute febrile illness

Abstract Background Over the past 20 years, visits to paediatric emergency departments (EDs) across Canada have steadily increased, with a higher proportion of presentations for lower acuity symptoms. Many paediatric institutions’ websites now provide information and recommendations for caregivers on common illnesses and reasons for seeing healthcare providers or going to the ED. Increasing the use of internet resources may improve health literacy and hopefully decrease ED use for lower acuity presentations like uncomplicated viral illness. Objectives The objective of this study was to assess whether caregivers presenting with children with lower acuity at triage were aware of and using the online resources provided by our paediatric institution to help with at-home management of febrile illnesses and to guide their decision to present to the ED. Design/Methods This was a cross-sectional study in a tertiary care university-affiliated paediatric ED in an urban setting. Participants were a convenience sample of caregivers of children 6 months to 17 years old with a fever 72 hours or less and triaged low acuity (Canadian Triage and Acuity Scale levels 3 to 5). Caregivers of children with underlying significant systemic illness were excluded. Consenting participants completed two questionnaires. The first questionnaire included demographic data, information on baseline internet utilisation, use of general online health information and our institutions’ website specifically, and whether use of those resources influenced their decision to present to the ED. After browsing dedicated web materials developed by our institution (“Before going to the emergency room” and “Fever”), questionnaire 2 asked for feedback on the website. Results From April to July 2023, 100 caregivers participated in the study (response rates questionnaires 1 and 2: 80% and 70%, respectively) (Table 1). Half (49%) of caregivers researched their child’s symptoms prior to coming to the ED (Table 2). Approximately one third (39%) of respondents were aware that our institution provided online information for caregivers about common symptoms and when to present to the ED. Half (51%) of caregivers who completed questionnaire 2 said they would not have come to the ED if they had read these resources prior (Table 3). Many (66%) respondents reported they would be “likely/very likely” to look up their child’s symptoms on the institutional website before going to the ED in the future. Conclusion Half of caregivers presenting to the ED for their child’s lower-acuity febrile illness conducted research on their child’s symptoms prior to visiting the ED and most were influenced in their decision to come to ED by what they found. Most caregivers were not aware that our institution had online resources available. Promotion of the institutional resources available to parents may empower parents to manage common symptoms at home and prevent ED visits for lower-acuity illness.

34 Improving language concordant care in the paediatric emergency department

Abstract Background Paediatric patients and families with limited English proficiency (LEP) experience worse health outcomes. Use of professional medical interpreter services (IS) helps ensure that all patients receive high quality care, regardless of their preferred language of communication. Objectives The aim of this quality improvement (QI) study was to improve language concordant care within a paediatric emergency department (ED) in downtown Toronto by increasing the rate of over-the-phone interpreter use by 50% by July 2024 and to understand common reasons for interpreter non-use. Design/Methods Using the model for improvement, we assembled an interdisciplinary team that included physicians, ED registration clerks, triage nurses, and language services staff to understand current workflow and develop targeted interventions aimed at addressing key drivers through multiple plan-do-study-act (PDSA) cycles. Interventions included introduction of a standardized script to capture language preference at ED registration, EMR-integrated preferred language notification and smart text template in provider notes for standardized IS use or non-use documentation, and departmental education. Our primary outcome measure was rate of over-the-phone IS use for all ED visits. Process measures were rate of EMR documentation of patients and caregivers with non-English language preference (NELP) and rate of provider documentation of IS use or non-use. Balancing measures included time to provider initial assessment (PIA) and ED length of stay. Results The baseline period (November 2022-April 2023) revealed an over-the-phone IS rate of 5.2% for all ED visits. The initial results from the first 6 months of the intervention period demonstrated an increase in physician documentation of IS use or non-use in patients with NELP, from 10% to 76%. Additionally, 18.6% of patients or caregivers with NELP had IS use per provider notes. Over the next 9 months of the intervention period, special cause variation is anticipated in the rate of IS use and rate of EMR documentation of NELP. The most common reasons for IS non-use were: ‘deemed unnecessary by provider’, ‘declined by family’ and ‘use of family member/friend as interpreter’. There was no change in PIA or ED length of stay for patients with NELP. Conclusion This QI initiative increased consistent provider documentation of IS use in ED patient records in one of the most linguistically diverse cities in the world. Future efforts will focus on exploring additional ways to capture language preference beyond registration, facilitating IS use in the ED, and addressing top reasons for non-use of IS in patients and caregivers with NELP.

04 Care for adolescents with substance use: A national survey of paediatric hospitals

Abstract Background Substance use is a recognized Paediatric health care issue. More than 9 in 10 individuals receiving treatment for substance use disorders report that their first use of substances occurred by young adulthood. The Canadian Institute for Health Information reported that 5% of hospital stays among Canadian youth in 2017-2018 were related to harmful substance use. In a study of youth with a first-time emergency department visit for a mental health problem between 2010 and 2014, most visits were due to substance related disorders. Despite this, little is known about practices relating to substance use in children's hospitals. Objectives 1. To describe how adolescents who present to Paediatric hospitals with substance use disorders or substance-related health issues are identified, assessed, and treated. 2. To identify best-practices that can inform national standards of care. Design/Methods An online questionnaire was utilized to obtain information on: 1. Clinical practices in the emergency department, inpatient services and ICU; 2. Hospital policies and practice guidelines; and 3. Hospital and community programs and resources. Recruitment emails were sent to hospital leaders (CEO or equivalent) at all 13 Paediatric hospitals. Leaders were asked to identify one individual to complete the survey on behalf of their hospital with input from relevant stakeholders in the various clinical areas. The survey was developed iteratively by a national group of 9 adolescent medicine clinicians and 2 Paediatric trainees. The survey was piloted at a single Paediatric hospital and refined. The survey was administered via RedCap technology. Results Survey response rate was 70% (9/13 hospitals). The mean number of contributors to each survey was 9 (range of 1-35). Overall, few hospitals utilized best practices consistently. There was inconsistency in the use of validated screening tools, use of clinical practice guidelines for monitoring and ongoing care and prescribing of nicotine replacement therapy and opioid agonist therapy. These inconsistencies were noted within each clinical setting (emergency department, inpatient services, and ICU), across services in each hospital, and between hospitals. With respect to hospital services, 5/9 had some type of consult team related to substance use (e.g., adolescent medicine), 4/9 had specialized substance use outpatient services, and 2/9 offered partial hospitalization/day treatment for patients with substance use issues. Local community-based substance use resources were identified as insufficient to address needs by 8/9 hospitals. Conclusion Inconsistencies in the care of adolescents with substance use disorders or substance-related health issues highlights the need for national guidelines for Paediatric hospital-based assessment and care, and enhanced coordination between services and systems of care for this patient population.

Physical Activity and Acute Care Utilization Among Older Adults With Mild Cognitive Impairment and Dementia.

People living with dementia have high rates of hospitalizations. Identifying factors that influence hospitalization is important. This study examines the influence of physical activity levels on risk of hospitalization and emergency department (ED) use among older people living with mild cognitive impairment (MCI) or dementia followed in our primary care practice in Rochester, Minnesota, United States. We included those age 55 years and older, who had a clinic visit between June 1, 2019 and June 30, 2021 and completed a social determinants of health questionnaire about physical activity levels (n = 3090). Physical activity was classified as sufficiently active, insufficiently active, or physically inactive. Risk of hospitalization and ED visits by physical activity levels were examined. People who were physically inactive were at higher risk of hospitalization and ED visits (p < .001) compared with those who were sufficiently active. This highlights an area for health promotion in people living with MCI and dementia.

Study protocol for a randomized controlled trial of Adapt 2 Asthma (A2A), a culturally relevant coping skills and asthma management intervention for Latinx Families

BackgroundLatinx children in the United States experience disparities in asthma control and asthma-related functional outcomes compared to non-Latinx White children, including more school absences, emergency department visits, and hospitalizations for asthma. Stress appears to play a role in asthma control, but interventions designed to address the role of stress in asthma control for Latinx children are limited.MethodThe current randomized controlled trial tests the effects of Adapt 2 Asthma (A2A), a family-based coping skills and asthma management intervention tailored to the stressors, strengths, and cultural beliefs of Latinx families, compared to an asthma self-management control arm (the Asthma Plan for Kids; APK). Latinx families of children ages 8 to 14 years old with asthma (target N = 280) are identified and enrolled from primary care clinics and randomly assigned to either A2A or APK. The intervention is delivered by lay health workers trained and receiving ongoing consultation from the study team. The primary outcome is child- and parent-reported asthma control, while secondary outcomes are child’s quality of life, lung function, school absences, and emergency department visits, and child and parent coping and family asthma management behaviors. Participants will be assessed at baseline, post-intervention, and at 6- and 12-month follow-up timepoints.DiscussionThis study has the potential to provide new evidence regarding the effects of culturally relevant coping and asthma management intervention strategies for Latinx children with asthma.Trial RegistrationClinicaltrials.gov NCT05118282. Registered on 11 November 2021.

Feasibility of Emergency Department-Initiated HIV Pre-Exposure Prophylaxis

Introduction: Pre-exposure prophylaxis (PrEP) for HIV—using antiretroviral medication in non-infected individuals to prevent HIV—has immense potential to slow the spread of the virus. However, uptake has been insufficient, and stark racial disparities exist in both HIV acquisition and PrEP usage, making PrEP access a health equity issue. A promising venue to engage high-risk populations in PrEP care is the emergency department (ED); however, existing ED PrEP initiatives have been costly or have had limited success. We hypothesize that two strategies could overcome these barriers: prescribing PrEP during an ED visit and providing patients with an initial supply of PrEP medication in the ED. Here, we describe the results of a qualitative study exploring multidisciplinary emergency clinicians and HIV clinicians’ needs and views about the feasibility of such an initiative. Methods: We conducted 22 semi-structured interviews with multidisciplinary clinicians from an urban, safety-net medical center in the ED and the on-site HIV clinic that provides PrEP services.We performed thematic analysis to summarize challenges and potential solutions described by participants. Results: Participants’ responses fell into three thematic categories: operational challenges; patient-level considerations; and potential impacts. Operational challenges highlighted the difficulty of PrEP initiation in a busy ED and clinician support needs. Patient-level considerations included the complex psychosocial needs of ED patients who could benefit from PrEP. Finally, participants anticipated that an ED-based PrEP initiation program could positively impact both individual patients and public health. Conclusion: Interviews with emergency department and HIV clinic staff revealed important considerations and potential solutions for ED-initiated PrEP workflows. Clinicians in both specialties were enthusiastic about such an initiative, which could facilitate its success. This study lays the groundwork for the future design of an efficient and innovative workflow to leverage the ED as an essential entry point into HIV prevention services.

Real-Time Ambulatory ECG Does Not Expedite Care.

Ambulatory ECG (AECG) monitoring is pivotal to the diagnosis of arrhythmias and can be performed with near "real-time" notification of abnormalities. There are limited data on the relative benefit of real-time monitoring compared with traditional Holter monitoring. This is a retrospective observational analysis of University of Utah Health patients who underwent ambulatory ECG studies from 2010 to 2022. The study cohort was stratified by patients with an ambulatory ECG that provides real-time event notification (non-Holter) versus those who do not (Holter). The outcomes were cardiac implantable electronic device procedure, ablation procedure, emergency department/hospitalization visit, and initiation of anticoagulation out to 6 months. We identified 20 259 patients, 16 650 with non-Holter studies and 3609 with Holter studies. Holter patients were younger (mean 52 versus 55, P<0.001), more often women (60.2% versus 57%, P<0.001), and had lower mean CHADS2-VA2Sc scores (1.7 versus 2.1, P<0.001). The median time to ablation procedure was 74 versus 72 (P=0.5), for Holter versus non-Holter, respectively. Median days to new cardiac implantable electronic device implantation was 54 days versus 52 (P=0.6); initiation of anticoagulation among patients not already treated was 42 versus 31 days (P=0.03). Time to first emergency department visit or hospitalization was 63 versus 57 (P=0.6). In multivariable models, there were no significant differences in time to intervention between Holter and non-Holter for each outcome. Real-time monitoring demonstrates mixed results in terms of reducing time to intervention, with the significant benefit limited to oral anticoagulation initiation. It is time to revisit clinical scenarios where real-time ambulatory monitoring may not improve health care efficiency.

Trends in CT examination utilization in the emergency department during and after the COVID-19 pandemic.

The increasing use of CT imaging in emergency departments, despite efforts of reducing low-value imaging, is not fully understood, especially during and after the COVID-19 pandemic. The aim of this study was to investigate the impact of COVID-19 pandemic related measures on trends and volume in CT examinations requested in the emergency department. CT examinations of the head, chest, and/or abdomen-pelvis (n = 161,008), and chest radiographs (n = 113,240) performed at our tertiary care hospital between 01/2014 and 12/2023 were retrospectively analyzed. CT examinations (head, chest, abdomen, dual-region and polytrauma) and chest radiographs requested by the emergency department during (03/2020-03/2022) and after the COVID-19 pandemic (04/2022-12/2023) were compared to a pre-pandemic control period (02/2018-02/2020). Analyses included CT examinations per emergency department visit, and prediction models based on pre-pandemic trends and inpatient data. A regular expressions text search algorithm determined the most common clinical questions. The usage of dual-region and chest CT examinations were higher during (+ 116,4% and + 115.8%, respectively; p < .001) and after the COVID-19 pandemic (+ 88,4% and + 70.7%, respectively; p < .001), compared to the control period. Chest radiograph usage decreased (-54.1% and - 36.4%, respectively; p < .001). The post-pandemic overall CT examination rate per emergency department visit increased by 4.7%. The prediction model underestimated (p < .001) the growth (dual-region CT: 22.3%, chest CT: 26.7%, chest radiographs: -30.4%), and the rise (p < .001) was higher compared to inpatient data (dual-region CT: 54.8%, chest CT: 52.0%, CR: -32.3%). Post-pandemic, the number of clinical questions to rule out "pulmonary infiltrates", "abdominal pain" and "infection focus" increased up to 235.7% compared to the control period. Following the COVID-19 pandemic, chest CT and dual-region CT usage in the emergency department experienced a disproportionate and sustained surge compared to pre-pandemic growth.