Introduction: Gaps in care integration and coordination contribute to emergency department (ED) crowding and preventable hospitalizations, necessitating innovative solutions to improve care transitions and reduce acute care use. This study evaluates whether attendance at a nurse-led ambulatory intermediate care clinic (AICC) reduces three-month ED visits and hospitalizations compared to missed AICC appointments. Methods: This retrospective cohort study at a single academic center analyzed AICC appointments from the first three years of clinic operations using multivariable logistic regression models, controlling for demographic, socioeconomic, and clinical factors. Our primary outcome measure was an ED visit within three months of the AICC appointment; our secondary outcome measure was hospitalization within three months. Robustness was assessed using Poisson, negative binomial, and zero-inflated models. Results: Among 2,698 appointments analyzed (mean age 51.5 years; 49.7% female), patients who attended their AICC appointment had a lower absolute ED visit rate compared with those who missed it (250/2,389 [10.5%] vs 47/309 [15.2%]; risk difference, 4.75%; 95% CI, 0.56-8.93%; P = .03). Missing an AICC appointment was significantly associated with greater odds of an ED visit (OR, 1.54; 95% CI, 1.07-2.21; P = .02). Hospitalization rates were 47.3% versus 53.4% (P = .04), although missing an AICC appointment was not significantly associated with increased hospitalizations (OR, 1.28; 95% CI, 1.00-1.64; P = .05). Findings were consistent across robustness analyses. Conclusion: The ambulatory intermediate care clinic model was associated with fewer ED visits but not reduced hospitalizations, suggesting that intermediate care can improve timely access and address acute care needs but may be insufficient to influence more complex drivers of inpatient admissions. Future research should explore strategies to enhance coordination and optimize the role of intermediate care within broader health system workflows.
Introduction: Recent recommendations suggest emergency medical personnel should consider rapid whole-body cooling for heat stroke patients. Cold-water immersion maximizes cooling rate and subsequent outcomes following heat stroke. Body bags filled with ice and water may provide portable, accessible partial cold-water immersion for this setting. The purpose of this study was to determine whole-body cooling rates when using body bags to facilitate partial cold-water immersion to treat exertional hyperthermia. Methods: A total of 9 healthy participants (8 male; mean [SD] age, 24 [4] years; height, 175 [7] cm; body mass, 83.6 [21.6] kg) completed our randomized-crossover field study. Following hydration verification, participants completed a self-paced 400 warm-up run, 1,609 m run, and 10-m sprints until rectal temperature (T-rec) reached 39.2 °C or volitional exhaustion. Following exercise, participants were cooled for a maximum of 30 minutes lying supine in the shade (control; CON) or in body bags filled with 20 gallons of ice water (5.2 [1.6] °C). Following cooling, participants sat upright for a 15-minute recovery. T-rec and heart rate (HR) were taken throughout exercise, every minute of cooling, and every 5 minutes of recovery. Participants completed both trials separated by 1 week in random order. Results: Wet bulb globe temperature between trials was not significantly different (grand mean, 28.43 [1.03] °C; P = .73). There was no difference in participant maximum T-rec (body bag, 38.98 [.23] °C; CON, 38.93 [.39] °C; P = .45); HR (body bag, 183 [14] beats per minute [bpm]; CON, 189 [13] bpm; P = .21); rating of perceived exertion (P >.99); thirst (P = .62); or thermal sensation (P = .73) during exercise. Fluid consumed (P = .40), body mass change (P = .90), 400 m run times (P = .19) and 1,609 m run times (P = .17) were no different between trials. Whole-body cooling rate for body bag was .102 (.04) °C/min, whereas CON produced a cooling rate of .040 (.04) °C/min (95% CI, .030-.095; P = .002). Total cooling time was significantly faster (13.2 (5.8) min) with BB compared to CON (27.6 (4.2) min; 95% CI, 9.2-19.5; P = .002). Conclusion: In clinical settings where full-body cold-water immersion is not feasible, or during emergency transport, partial immersion via body bags offers acceptable cooling rates for hyperthermic patients. Emergency medical personnel could apply these data for support in updating heat stroke protocols to include partial immersion via body bag during transport, or immediately upon emergency department arrival.
Background: Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Rural residence and low community income are independently associated with poorer health outcomes, mediated by variations in injury mechanism and healthcare access. We evaluated the impact of geographic location on injury patterns and acute‐care metrics in adults with TBI treated at Maryland’s statewide Level I trauma center. Methods: Adults (≥18 years of age) with radiographically confirmed TBI admitted between 2017 and 2021 were identified retrospectively from the institutional trauma registry. Rural residence was defined using Rural-Urban Commuting Area codes. This single-center study included only patients surviving to hospital admission. Primary outcomes included hospital length of stay (LOS) and discharge to hospice or death. Secondary outcomes included intensive care unit (ICU) and ventilator days and discharge disposition. Results: Of 2,812 patients diagnosed with TBI during the study period, 267 (9.5%) resided in rural areas. Compared with nonrural patients, rural patients were older (median age 67 vs 60 years, P < .001) and lived in lower income communities. However, after adjustment for demographic and clinical covariates, rural residence was not associated with higher hospital LOS quartile category (adjusted odds ratio [aOR] 1.18; 95% CI, 0.91-1.53; P = .20), discharge to hospice or death (aOR 1.67; 95% CI, 0.95-2.94), or discharge to a nonhome setting (aOR 0.93; 95% CI, 0.66-1.31). Groups showed no significant differences in critical care use, including ICU and ventilator durations. Worse outcomes were associated primarily with injury severity, including lower Glasgow Coma Scale scores and higher Injury Severity Scores. Conclusion: In a well-established regional trauma network, we found that among patients admitted with traumatic brain injury, residing in a rural area was not independently associated with worse in-hospital outcomes compared to patients who resided in nonrural (urban and suburban) communities. These findings suggest that a coordinated statewide trauma triage and access to tertiary neurotrauma care may help other systems similarly reduce rural disparities after severe head injury.
Introduction: Prehospital triage challenges often lead to suboptimal choices and delayed treatment for stroke patients. The objective of the study was to evaluate whether a decision-support interface to assist in stroke triage to an appropriate hospital could reduce emergency medical technicians’ (EMT) mental workload. Methods: This randomized crossover study was conducted between February and March 2025. Each participant completed two 12-minute simulated trials in randomized order: current dispatch orders without decision support and a decision-support interface. We assessed mental workload—the mental effort required to make hospital transport decisions under time pressure during prehospital stroke triage—using heart rate variability (HRV) metrics and the National Aeronautics and Space Administration Task Load Index (NASA-TLX). System usability was assessed using the System Usability Scale. The primary outcome was the root mean square of successive differences for each participant after completing the two trials. The secondary outcomes included the differences of NASA-TLX, System Usability Scale, and other heart rate variability parameters, including mean R-R interval (meanRR), mean heart rate, percentage of successive R-R intervals that differ by more than 50 milliseconds, low-frequency power (LF), high-frequency (HF) power, and the LF/HF ratio. Subgroup analyses examined differences by sex, education, age, and years of service. Results: A total of 35 emergency medical technician (EMT)-intermediate participants (mean age, 27.5 [5.3] years) completed the study. For the primary outcome, the root mean square of successive differences increased significantly (28.1 [13.0] vs 32.4 [13.6] milliseconds; mean difference, 4.3 milliseconds [95% CI, 1.57–6.99]; P < .01), indicating reduced mental workload when the participants used the decision-support interface. For the secondary outcomes, mean heart rate (77.5 [8.6] vs 73.8 [10.6], P < .01) decreased, mean R (784.2 [89.5] vs 808.9 [87.3], P < .01) increased, and HF power (370.1 [291.7] versus 482.6 [433.9], P = .02) increased, suggesting reduced mental workload when the participants used the decision-support interface. The mental demand scores in NASA-TLX decreased from 62.5 (14.6) to 35.5 (17.0). Emergency medical technicians with 1.0–1.5 years of service reported higher System Usability Scale scores than those with 1.5–3.0 years (84.4 versus 71.3, P = .02), and 82.9% of participants rated the system as acceptable (System Usability Scale score ≥ 70). Conclusion: This study demonstrated that integrating a web-based decision-support interface effectively reduces mental workload and psychological stress among EMTs in stroke triage.
Climate change is increasing the frequency, duration, and intensity of extreme heat events, creating a growing public health threat for older adults. Age-related physiologic decline, comorbid chronic diseases, polypharmacy, and social vulnerability all contribute to reduced heat tolerance and higher rates of heat-related morbidity and mortality. Emergency departments (ED) are increasingly encountering older adults presenting with minor heat illness, heat stroke, and exacerbations of chronic illnesses triggered by heat exposure. This review synthesizes current evidence describing why older adults are disproportionately affected by extreme heat, highlights key social and environmental determinants of vulnerability, and outlines clinical and public health strategies that emergency clinicians and EDs can assist with to reduce risk. As global temperatures rise, proactive prevention, early recognition, and coordinated community interventions are essential to protect this high-risk population.
Introduction: Patients with hepatic encephalopathy frequently visit the emergency department, and these visits are expected to rise in the coming years due to an increased prevalence of liver disease in the United States. Accordingly, we sought to define a comprehensive and efficient approach for emergency physicians to evaluate, treat, and determine the optimal disposition of patients presenting with possible or confirmed hepatic encephalopathy and its complications. Methods: We reached consensus recommendations through a structured literature review and a modified Delphi technique, informing an expert panel of academic and community emergency physicians convened by the American College of Emergency Physicians. Results: We created the assess, look, treat, evaluate risk, reassess, disposition (ALTERD) framework as a digital point-of-care tool to support clinicians in guiding key bedside steps involved in the diagnosis and care of patients across the spectrum of hepatic encephalopathy. Conclusion: A collaborative expert panel process can create an emergency department-focused, easily accessible, and comprehensive digital tool to complement workflows and improve the care of a vulnerable and growing patient population.
Introduction: Healthcare is a significant contributor to global greenhouse gas emissions, with emergency departments being among the most resource-intensive settings. Despite increasing awareness of climate change and its health implications, structured sustainability education remains lacking in emergency medicine graduate medical education training. We evaluated the impact of a brief, educational intervention on emergency medicine (EM) residents’ knowledge, attitudes, and self-reported behaviors related to sustainability. Methods: We conducted a prospective pre/post interventional study at two community-based EM residency programs. Emergency medicine residents completed a baseline survey assessing sustainability-related knowledge, attitudes, and self-reported behaviors, followed by a video on sustainable clinical practice and a peer-reviewed paper on the environmental impact of inhalers. Immediate postcourse and one-month follow-up surveys were administered to evaluate short- and intermediate-term changes. Our primary outcome measure was change in sustainability-related knowledge scores. Secondary outcomes included changes in attitudes toward sustainability and self-reported sustainability-related clinical behaviors. Survey responses were analyzed using descriptive statistics, paired t tests and repeated-measures analysis of variance, as appropriate. Results: Of 41 eligible EM residents across two residency programs, 34 completed the baseline survey (82.9%), 28 completed the immediate post-intervention survey (68.3%), and 30 completed the one-month follow-up survey (73.2%). Knowledge scores at baseline were 55.0% and increased to 68.0% immediately after the intervention (P < .001). At one month, knowledge scores remained higher than baseline (65.0%) (P = .003). Attitudes improved significantly immediately post-intervention (P = .001), despite already neutral-to-positive baseline levels. Two self-reported behavior items improved at one month: preferential prescribing of dry-powder inhalers, which were described in the educational materials as having less of an environmental impact than aerosolized inhalers (12.0% to 37.0%, P < .050) and self-reported efforts to reduce unnecessary waste (56.0% to 87.0%, P < .050), with overall self-reported behavior change (P = .001). Nebulizer-related prescribing did not significantly change. The open-ended item showed similar thematic patterns at both baseline and after one month, with most residents describing simple waste-reduction actions (eg, minimizing disposables), and no significant shift in qualitative categories. Discussion and Conclusion: A brief, structured sustainability module delivered via a video format was feasible and well-received by EM residents. Preliminary data suggest improvements in knowledge, attitude, and self-reported behaviors, highlighting the potential for scalable sustainability education within graduate medical training. However, these findings should be interpreted in the context of a small sample size and self-reported outcomes.
Introduction: High-quality cardiopulmonary resuscitation (CPR) is essential to improve survival in cases of cardiac arrest. However, skill acquisition based solely on instructor observation has proven to be limited. In this context, real-time feedback devices emerge as promising tools to optimize CPR training.Objective: In this study our goal was to evaluate the effect of using a real-time feedback device on the quality of CPR performed by medical students at a public university in Colombia. Methods: This was an experimental study with fourth-year medical students, randomly assigned to two groups. Both groups received the same initial theoretical and practical training in basic CPR. Subsequently, the intervention group practiced with a real-time feedback device, while the control group trained without technological feedback. The primary outcome measure was the target of chest compressions, simultaneously meeting both a rate of 100-120 compressions/minute and a depth of 5-6 cm (maximum value: 100%), as well as ventilations delivered within the 500-600 mL volume range. Secondary outcomes included isolated data on compression depth and rate during two simulated scenarios: hands-only CPR for two minutes and five cycles of 30 chest compressions and two ventilations. Results: Of 106 eligible participants, 98 (92.5%) completed the test (46 intervention / 52 control). Regarding the primary outcome, the intervention group showed significantly higher compliance with the compression target compared to the control group (median values: intervention group 31% vs control group 0%, P < .001). In the hands-only CPR test, the intervention group achieved a higher compression target (72% [40.7-81] vs 3.4% [0-40]; P < .05) and better depth control (5.5 cm [5-5.6] vs 6 cm [5.6-6.1]); P < .05], with no differences in rate (P = .71). In the test with cycles of 30 chest compressions and two ventilations, the intervention group performed better, with a higher compression target (73% [5-83] vs 0.5% [0-19]), P< .05) and better depth control (5.5 cm [5-5.8] vs 6 cm [5.9-6.1], P < .05). No significant differences were observed in ventilation. Both groups had a median target completion of 0% with tidal volumes (intervention group, 265 mL; control group, 291 mL), accounting for failure at well below the recommended 500-600 mL. Conclusion: Real-time feedback significantly improved chest compression quality in medical students, although ventilation difficulties persisted. Future research is needed to assess long-term skill retention and clinical application.
INTRODUCTION:Methamphetamine-associated heart failure with reduced ejection fraction is a serious consequence of methamphetamine use often underrecognized in the emergency department (ED). Point-of-care ultrasound (POCUS) offers rapid, non-invasive cardiac screening for high-risk populations. This study evaluated the diagnostic yield of POCUS for detecting methamphetamine-associated heart failure with reduced ejection fraction in ED patients who use methamphetamine. METHODS:We conducted this prospective cohort study between December 2020-February 2024 at an urban Level I trauma center ED. The primary outcome was diagnostic yield of cardiac POCUS for abnormal left ventricular ejection fraction (LVEF) and abnormal sex-specific left ventricular end-diastolic diameter in patients with methamphetamine use, with secondary analyses assessing associations with use duration and frequency. Diagnostic yield was calculated as the proportion of completed POCUS examinations identifying abnormalities. We used E-point septal separation to calculate LVEF; < 40% was abnormal. Left ventricular end-diastolic diameter abnormality (> 5.8 cm males, > 5.2 cm females) was categorized as mild, moderate, or severe (mild, 5.9-6.3/5.3-5.6; moderate, 6.4-6.8/5.7-6.1; severe, > 6.8/> 6.1 cm males/females). Physician-performed POCUS assessed LVEF and left ventricular end-diastolic diameter in patients with a methamphetamine use history and a comparison group of non-users. RESULTS:Of the 136 enrolled patients, 84 (61.8%) reported methamphetamine use. Among methamphetamine users, diagnostic yield of cardiac POCUS was as follows: reduced LVEF in 22 of 70 with measurable LVEF (31.4% [20.9-43.6%]); any sex-specific left ventricular end-diastolic diameter abnormality in 30 of 84 (35.7% [25.6-46.9%]); and severe sex-specific left ventricular end-diastolic diameter abnormality in 15 of 84 (17.9% [10.4-27.7%]). Corresponding values in non-users were 3 of 52 (5.8% [1.2-16.0%]; P < .001), 10 of 52 (19.2% [9.6-32.5%]; P = .05), and 3 of 52 (5.8% [1.2 - 16.0%]; P = .07), respectively. Longer duration (odds ratio [OR] 6.05, 95% confidence interval [CI] 1.46-25.10) and higher frequency (OR 5.93, 95% CI, 1.52-23.06) of methamphetamine use were associated with reduced LVEF. CONCLUSION:Cardiac point-of-care ultrasound demonstrated a clinically significant diagnostic yield in detecting methamphetamine-associated heart failure with reduced ejection fraction among methamphetamine users in the ED, suggesting POCUS could aid early detection in this population, potentially streamlining management before disease progression.
INTRODUCTION:Video methods used in medicine have been described as the "gold standard" because they show events as they occurred and with a level of detail unattainable when events are reconstructed using other methods. In stimulated recall, video or pictures during interviews prompt discussion about participants' thoughts or feelings when images were captured. Coupled with video, stimulated recall can deepen researchers' understanding of a participant's thinking at the time. However, conducting video-based stimulated recall interviews with participants is poorly described in the literature because of word count limits in today's journals. In this paper we describe how we used video with stimulated recall interviews to learn how the diagnostic process evolves for emergency physicians. METHODS:We used the theory of distributed cognition to describe how information processing develops over time and occurs across physicians, the technologies used, and social organization. We conducted a qualitative study, collecting data in pediatric and adult emergency departments (ED) of an academic Level I trauma center. Participants wore head-mounted video cameras for two hours while providing care to ED patients and revealed their thinking throughout the diagnostic process in subsequent stimulated recall interviews. We reviewed video recordings to identify situations related to the diagnostic process or to one of the concepts in distributed cognition. We identified short video clips from each session to display during interviews and prepared accompanying questions. Stimulated-recall interviews were conducted using video conferencing technology, audio recorded, transcribed, and verified for accuracy. We used content analysis to analyze results. RESULTS:Eleven attending physicians from February 2022-May 2023 (five from the pediatric ED and six from the adult ED) interacted with 52 patients over a total of 24.4 hours on video. We obtained patients' permission to film encounters before a participating physician provided care, wearing the head-mounted camera. We conducted individual stimulated recall interviews (mean 53 minutes, range 33-63 minutes) with all 11 physicians, which uncovered perspectives beyond what was revealed on film. For example, the complexity of cognition resides in patients as well as physicians. Thus, physicians must exert great effort to elicit the patient story and make a likely diagnosis in the chaotic, noisy environment of the ED. CONCLUSION:Using innovative methods to uncover emergency physicians' cognitive processes has the potential to advance our understanding in other settings. This methodology brings awareness to how one's thoughts can become visible and, thus, amenable to reflection and change.
INTRODUCTION:Our study objective was to share the experiences of four public emergency departments (ED) caring for patients with complications of gluteal autologous fat transfer (AFT), colloquially known as Brazilian butt lifts, to provide emergency physicians with a better understanding of these patients and potential complications associated with the procedure. METHODS:Jackson Health System in Miami, Florida, undertook an institutional initiative to prospectively collect data on patients presenting to any of the system's EDs with gluteal AFT complications from October 2020-May 2023. We abstracted patient charts for demographics, disposition, lab values, diagnoses, and care-related charges to generate descriptive statistics. Our primary outcome measure was diagnostic code and diagnostic category. Secondary outcome measures were hemoglobin on presentation, units of blood transfused, admission level of care, hospital charge, length of stay, and mortality. RESULTS:Of 234 potentially relevant patient charts identified by our hospital protocol, 157 patients met our criteria. All were female, with an average age of 33. A total of 123 patients were from out of state, and one was international. The most common diagnoses were anemia/bleeding (81 patients), followed by pain (65), cardiac (36) and hypovolemia/dehydration (32). Our analysis revealed that 86 patients presenting to the ED required admission (54.8%), with 12 patients requiring intensive care unit care (7.6%). There was one death (0.6%). Total hospital charges for this cohort equaled $2,822,540, averaging $17,977 per patient. CONCLUSION:Gluteal AFT procedures are associated with a wide range of complications, morbidity, and mortality. These patients have a high admission rate and the potential to be critically ill. Patients travel from around the country to have these procedures performed, and it is crucial that EDs nationally are prepared to care for them.
BACKGROUND:Intravenous (IV) fluids are commonly used in emergency departments (ED), but their supply can be vulnerable to national shortages. In September 2024, Tropical Storm Helene disrupted production at a major manufacturing facility, triggering a nationwide IV fluid shortage. In response, our ED implemented a multiphase intervention aimed at reducing non-essential fluid utilization. We aimed to reduce total IV fluid use in the ED by at least 25% through a staged, systems-based conservation strategy. METHODS:We conducted a single-center, retrospective, pre-post quality improvement initiative in a tertiary academic ED with approximately 57,000 annual visits. Interventions were deployed across three Plan-Do-Study-Act cycles: 1) clinician education on fluid stewardship (7 days); 2) protocol modifications to reduce routine IV placement (11 days); and 3) electronic health record (EHR) clinical decision support tools, including an interruptive alert and oral hydration order set (32 days). We analyzed daily fluid administration volumes, and ED census data from September 2024 (pre-intervention) and November 2024 (post-intervention). The primary outcome was total IV fluid usage per day; a secondary outcome was IV fluid volume per patient encounter. We compared mean daily utilization between periods using two-sample t-tests. RESULTS:Average daily IV fluid use declined from 56.3 to 24.8 liters, a 56.0% relative reduction (P < .001), while ED volume remained stable (155.4 vs 153.1 encounters/day pre- vs post-intervention). Normalized per-encounter IV fluid administration decreased from 0.36 to 0.16 liters per visit (P < .001), representing a 56% relative reduction. Assuming a pharmacy acquisition cost of approximately $2 per liter of crystalloid, the intervention was associated with an estimated reduction of $63 in IV fluid expenditures per day (31.5 liters), or $1,890 over the 30-day post-intervention period. CONCLUSION:A structured intervention combining education, protocol changes, and EHR decision support significantly reduced IV fluid use in the ED without disrupting operations. This approach may serve as a scalable model for resource stewardship during future supply chain crises. The most substantial reductions occurred during the final intervention phase involving EHR-based decision support.
INTRODUCTION:Diagnostic efficiency in the emergency department (ED) is crucial for workflow. Among these, urinalysis (UA) is a key test for abdominopelvic complaints. Prolonged UA turnaround times can extend patient length of stay and reduce patient satisfaction, highlighting the need for improvement. In this study qw sought to measure the correlation between UA turnaround times and time to disposition. METHODS:We conducted a retrospective analysis of discharged ED patients with abdominopelvic complaints who had a UA ordered between January-August 2022. Electronic health records data included UA order-to-result time, urine human chorionic gonadotropin (hCG), time to disposition, and complete blood count (CBC) turnaround time as a venipuncture comparator. Spearman correlation coefficients assessed associations between lab processing times and time to disposition. RESULTS:Among 6,708 discharged patients included in the study, 3,795 presented with abdominopelvic complaints. In this subgroup, 3,688 UAs, 1,285 urine hCG tests, and 2,966 CBCs were obtained. Median times from UA order-to-specimen receipt and result were 65 (IQR 29-138) and 92 (53-168) minutes, respectively. A modest positive correlation was observed between UA order-to-result time and time to disposition (ρ = 0.46), relative to CBC order-to-result time (ρ = 0.29). The relationship was slightly weaker for urine hCG (ρ = 0.35). Laboratory turnaround times showed minimal correlation with ED time to disposition (UA ρ = 0.04; urine hCG ρ = 0.03; CBC ρ = 0.09). CONCLUSION:Urinalysis acquisition and processing times are modestly correlated with time to disposition in patients with abdominopelvic complaints. Reducing collection time for UA and urine hCG tests may improve throughput for this patient cohort.
INTRODUCTION:Penicillin allergy is one of the most reported drug allergies, but studies have shown that patients who report an allergy frequently do not have a significant reaction when challenged. Avoidance of penicillin or beta-lactam antibiotics in these patients results in increased hospitalization costs, suboptimal antibiotic therapy, and risk for subsequent infection with multidrug resistant organisms. METHODS:This was a single-center, retrospective chart review that included patients ≥ 18 years of age with documented penicillin allergy who presented to the emergency department (ED) over a one-year period. Clinical pharmacy specialists in the ED reviewed and stratified patient allergy risk. Patients with low-risk allergy histories who were to be admitted and gave formal consent were given an oral amoxicillin challenge and then observed in the ED for at least one hour. Patients who were eligible for challenge but were to be discharged from the ED were given the option to be seen in the allergy clinic. The primary outcome was the incidence of adverse reactions related to the oral amoxicillin challenge for patients. An exploratory secondary outcome was the average length of stay (LOS) in the ED for oral amoxicillin-challenged patients compared to the average LOS for non-oral amoxicillin-challenged patients. We performed descriptive statistics on all variables. RESULTS:A total of 144 patients received an allergy assessment in the ED, 20 who received an oral amoxicillin challenge and 124 who did not. Baseline characteristics were similar in both groups. The average total LOS in the oral amoxicillin-challenged patients was a non-significant 36 minutes longer compared to the non-challenged patients (P = 0.4). Of 144 patients, 71 (49%) had their penicillin allergy removed as a result of the challenge.. One patient experienced a mild and self-limited reaction to the oral amoxicillin challenge (0.7%; 95% CI, 0.02-3.8%). CONCLUSION:An ED pharmacist-led, penicillin de-labeling protocol was safe and feasible. A secondary exploratory analysis showed no significant difference in length of stay between patients who received the oral amoxicillin challenge in the ED vs those who did not. Performing a proper penicillin allergy evaluation in the ED can have lasting benefits for patients and antimicrobial stewardship.
BACKGROUND:Prevalence of heart failure is increasing, with an associated rise in emergency department (ED)-related care. Social determinants of health (SDoH) are associated with adverse health outcomes, but the extent to which they influence ED use for heart failure care is poorly understood. We sought to describe the relationship between community-level social vulnerability and ED revisits and hospital admissions for heart failure within a single health system. METHODS:We conducted a retrospective review of Social Deprivation Index (SDI) scores (higher score = more deprivation) by ZIP code paired with administrative clinical data. Zero-hurdle regression was used to model the relationship between SDI and ED revisits within 90 days of a prior ED visit for heart failure (logistic model for > 0 revisits; Poisson model for count of revisits). We used a mixed-effects logistic model-accounting for repeat visits-to test the association of SDI with hospital admission at any given ED visit. RESULTS:From January 2022-December 2023, there were 3,569 ED visits from 2,406 patients. Each standard deviation increase in SDI (30.3) was associated with increased odds of at least one 90-day revisit (OR, 1.53; 95% CI, 1.08-2.16). Higher SDI was also associated with more 90-day revisits, with varying magnitude by hospital. After adjusting for characteristics of prior ED visit, SDI was not associated with hospital admission. CONCLUSION:Our results suggest that area-level social vulnerability influences the decision to seek heart failure-related care in the ED. Patients from more deprived areas may not have more severe clinical presentations, however, as evidenced by lack of association of SDI with hospital admission.
Introduction: Historically, flumazenil was employed as both a diagnostic aid in unresponsive patients and as an antidote for suspected benzodiazepine overdose in both emergency departments and out-of-hospital settings. However, its prehospital application has been historically constrained by long-standing concerns regarding adverse events, leading many emergency medical service (EMS) systems to restrict or avoid its use. The use of flumazenil in the prehospital setting remains underreported in the literature, despite its inclusion in the treatment protocols of various EMS agencies. We conducted a descriptive analysis of the use of flumazenil by EMS in the out-of-hospital setting across the state of Kansas over a five-year period. We characterize the frequency, indications, patient outcomes, and associated adverse events of flumazenil administration, thereby contributing to a better understanding of its role, safety, and clinical relevance in prehospital care. Methods: We performed a retrospective observational cohort design to evaluate the use of flumazenil by EMS clinicians in the state of Kansas from January 2015–August 2020. Patient care reports documenting prehospital administration of flumazenil were obtained from the Kansas Board of EMS. Data extracted included demographics, indications, initial and subsequent Glasgow Coma Scale (GCS) scores when available, clinical response, and the occurrence of adverse events. Our primary outcome measure was GCS improvement following administration, with secondary outcome measures including patterns and outcomes with flumazenil use in the prehospital setting, clinical response, and occurrence of adverse side effects. Results: A total of 80 cases involving EMS administration of flumazenil were identified with 69 cases meeting inclusion criteria. No seizures or adverse events were associated with flumazenil use (0/69; 95% CI, 0–4.3%), even in administrations with possible contraindications. Of the 69 cases analyzed, 24 cases documented suspected benzodiazepine overdose, all of which documented neurologic improvement (24/24; 95% CI, 87.5–100%), with 17 receiving flumazenil alone and 7 with naloxone coadministration. Conclusion: In this small sample, no adverse events were noted with flumazenil administration in the prehospital setting. Flumazenil administration was commonly associated with documented improvement in GCS in suspected benzodiazepine overdose. These findings suggest that exclusion in EMS protocols based solely on concern for adverse events in the prehospital setting can be reconsidered. Further research is needed to better define its safety, efficacy, and clinical utility in this setting.
Introduction: Alcohol use disorder (AUD) contributes to significant healthcare costs, disease, emergency department (ED) crowding, and recidivism. Naltrexone is a treatment for AUD that has been approved by the U.S. Food and Drug Administration and holds promise as a pharmacologic intervention for ED patients with AUD. We hypothesized that subjects who received naltrexone in the ED would have associated reduced recidivism in the 30 days after treatment. Methods: This was a retrospective chart review of an AUD quality program comparing ED visits in the 30 days before with 30 days after initiation of naltrexone in the ED. We performed this study at two academic hospitals (one a Level I trauma center) and one community hospital. Results: A total of 297 subjects (median age 43 years, 69.5% male) made 331 naltrexone index visits during the study period. There was no difference in the number of ED visits before versus after the index visit among all subjects (0 median visits before [interquartile range 0-1] versus 0 median after [0-1]). Subjects who were frequent ED users (defined as ≥ 4 ED visits in the 90 days preceding (N=56 [16.9%]) had a significant reduction in ED visits after administration of naltrexone (median of 5 visits [3-8] before versus 3 [2,6] after), with 36 of these subjects (64.3%) having reduced ED visits in the 30 days after naltrexone administration. Conclusion: Naltrexone administered in the emergency department had no associated change on the study population’s rates of recidivism for alcohol use disorder, but it was associated with reduced ED recidivism in subjects with high ED use.
INTRODUCTION:Understanding changes in opioid overdose-related emergency department (ED) visits and ED-based opioid use disorder (OUD) treatment post-coronavirus disease 2019 (COVID-19) pandemic can inform ongoing efforts to address the opioid crisis. We aimed to examine trends in opioid overdose-related ED visits, ED-based medication for OUD (MOUD) treatment, and appendicitis-related ED visits (as a control) before and after the initial COVID-19 peak in April 2020. METHODS:We conducted an interrupted time series analysis of monthly ED visits from January 2017-December 2022 at three hospitals in California. We modeled pre- and post-COVID-19 visit trends and the change in trend from pre- to post-COVID-19 peak using linear regression controlling for study site. Our primary outcome included monthly rates of opioid overdose-related ED visits, with monthly rates of ED visits with MOUD treatment as a secondary outcome. Appendicitis-related visits served as a control for temporal trends. RESULTS:Of the 781,488 ED visits across the entire study period, there were 2,536 (0.32%) opioid overdose-related visits, 9,755 (1.25%) MOUD treatment visits, and 1,123 (0.14%) appendicitis-related visits. Pre-pandemic, monthly increases were observed in opioid overdose-related visits (6.7 visits/10,000 per month, 95% confidence interval [CI] 2.6-10.8, P = .001), MOUD-positive visits (34.9 visits/10,000 per month, 95% CI, 26.0-43.7, P < .001), and appendicitis visits (2.5 visits/10,000 per month, 95% CI, 1.2-3.9, P < .001). After April 2020, only MOUD-positive visits showed an immediate (level change) increase (49 visits/10,000 or 34% of April 2020 projected pre-COVID-19 visit rates, 95% CI, 26.1-71.9, P < .001), with opioid overdose-related visits subsequently declining (-4.6 visits/10,000 per month or -11% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -7.2 to -2.0, P = .001). Across the entire pre- to post-COVID-19 period, significant decreases in overall visit trends were observed across all visit types, greatest for MOUD-positive visits (-39.2 visits/10,000 per month, or -27% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -51.5 to -26.8, P < .001), followed by opioid overdose visits (-11.3 visits/10,000 per month, or -27% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -16.1 to -6.5, P < .001) and appendicitis visits (-4.2 visits/10,000 per month, or -23% of April 2020 projected pre-COVID-19 visit rates, 95% CI, -7.2 to -1.2, P = .01). CONCLUSION:From pre- to post-initial COVID-19 peak, absolute ED-based MOUD treatment trends declined over three times faster than those of opioid overdose-related ED visits (although percentage changes relative to expected April 2020 rates were both -27%). These findings may reflect reduced perceived urgency as overdose presentations decreased and a shift away from crisis-driven implementation, underscoring the need for intentional integration of MOUD into routine ED practice to sustain treatment capacity.
