Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. Emergency department (ED) providers anecdotally report seeing more pediatric patients with depression and behavioral issues during the fall-winter season. We hypothesize a seasonal pattern in ED pediatric visits with behavioral health (BH) complaints at our institution, with a nadir in summer months. The objective of this study is to determine if there is seasonal variation, and, if so, if the same pattern exists in the adult population. Average monthly number of pediatric (under 18 years) BH ED visits per season were calculated from July 2015 to January 2019 in a community teaching ED with an annual census of 83,000 patients, 15% under the age of 18. Spring was defined as the months of March, April and May; Summer was June, July and August; Fall was September, October and November; and winter was December, January and February. A nonparametric Kruskal Wallis test was used to compare the average monthly number of visits across seasons. Adult BH ED visits were calculated in the same manner across the same time period. The average number of pediatric BH ED visits differed significantly (p<0.001) across seasons. Median monthly pediatric BH visits per season were: spring 95 (IQR 92-103) summer 52 (IQR 46-61), fall 82 (IQR 73 to 89), and winter 80 (IQR 78 to 86). The variation was not mirrored in the adult population over the same time period (p=0.547), where the median seasonal number of BH visits ranged from 263 to 285 a month. There is seasonal variation in total counts of pediatric BH ED visits at our institution. The increase of presentations in non-summer months could be due to the impact of shorter daylight hours, cooler weather and less outdoor activities in the pediatric population leading to dysmorphic affect and more behavioral complaints. In contrast, the lower incidence of complaints during the summer may be due the lack of organized supervision of high-risk pediatric patients. When children are not in school, there is less professional supervision and, therefore, less reporting of high-risk activities. This highlights the need for divertive measures, which involve a multifactorial approach to pediatric wellbeing, during the summer months for these patients.

The objective of this study was to evaluate the effect of a 4-hour palliative care curriculum (PCC) on emergency medicine (EM) resident comfort with key palliative care skills and knowledge of the subject material. The primary outcome was the change in self-reported comfort with key palliative care skills. The secondary outcome was resident knowledge of best practices related to end-of-life care. It was hypothesized that participation in the curriculum would increase comfort level and knowledge of subject material in the immediate follow-up, but that some of this would be lost at 6 months. This was a prospective, survey-based study. A 4-hour PCC, based on the EPEC-EM course, was designed and taught by a certified EPEC-EM trainer as part of the departmental conference series at an EM residency program. Residents were asked to a survey before, immediately after, and 6 months after completion of the curriculum. This survey assessed resident comfort with relevant palliative care skills on a five-point Likert scale. Resident knowledge of best practices to guide end-of-life conversations was assessed by nine multiple choice questions. Of 99 surveys issued, 66 were completed for a 67% response rate; 31 of 33 eligible residents completed at least one survey. At the immediate follow up, survey results showed a significant increase in resident comfort for all skills except informing a family member of a loved one’s death, breaking bad news to a patient, and managing the pain of a terminal cancer patient. At 6-month follow-up, resident comfort rating continued to trend upward with all skills showing significant improvement over the pre-curriculum assessment except for completion of a POLST (Figure). The average resident comfort rating for all palliative care skills prior to the PCC was 3.04 (“neutral” sentiment). At immediate and 6-month follow-up, the average score was 3.84 and 4.05 (“somewhat comfortable”), respectively. There was no significant increase seen in the scores on the knowledge-based multiple choice questions immediately or at 6 months following the PCC. Implementing a brief PCC as part of resident conference series improves resident comfort with key palliative care skills in the ED that not only persists at 6 months, but demonstrates further increase. This may be due to subsequent opportunities for residents to apply their palliative care skills in a clinical environment. Further opportunities for research would include application of a similar intervention across multiple residency training sites or institution of a follow-up training session to reinforce the skill set even further.

Emergency department (ED) patients with suspected small bowel obstruction (SBO) are often screened with abdominal x-rays (AXR). Negative or inconclusive results generally necessitate subsequent evaluation with computed tomography (CT) scan. Use of point-of-care ultrasound (POCUS) as an initial screening test for SBO may reduce the need for CT imaging, decrease exposure to radiation, and expedite patient care. The primary objective of this study was to evaluate the accuracy of POCUS in the diagnosis of SBO.

Background: Systemic Inflammatory Response Syndrome (SIRS) criteria are used to classify and initiate care for patients with presumed infection. However, SIRS is also present with noninfectious causes such as burns, pancreatitis and hemorrhage. More often, SIRS implies sepsis. Since pneumonia is the most common source of sepsis, chest radiography (CXR) are routinely obtained in the evaluation of patients with SIRS, whether or not they demonstrate respiratory abnormalities (RA). Evidence is lacking that demonstrates the utility of ordering CXRs for patients who present with SIRS criteria but have no respiratory abnormalities. Study Objectives: Our objective is to determine the prevalence of pneumonia and the predictive properties of CXR in the evaluation of SIRS for patients with and without respiratory abnormalities. We hypothesize that patients who present to the emergency department (ED) with SIRS criteria and no RA have a lower prevalence of pneumonia and, therefore, do not require a CXR on initial work-up. Methods: In an institutional review board-approved retrospective chart review conducted in a community ED, consecutive patients with CXR in the ED in December 2010 were identified by billing codes. Patients with 2 or more SIRS criteria were included. Patients were excluded with age less than 18, known pneumonia at presentation, chronic abnormal CXR, or DNR/comfort care only. A standardized data collection sheet was used. Subjects were stratified by the presence or absence of RAs, defined a priori as dyspnea, cough, chest pain, hypoxia (Sats <90% on RA), tachypnea (RR>20), or focal lung findings on exam. The hospital discharge diagnosis was used as the gold standard to determine the presence or absence of pneumonia. Radiology interpretation of CXRs as a new infiltrate, opacity, or effusion was considered to be a positive test result. All other interpretations were considered negative test results. Descriptive statistics and Fisher's exact test were used. Results: 2152 CXRs were obtained in the ED in December 2010. 1053 (49%) of the patients tested with CXR in the ED during the study period were screened, and 193 met inclusion/exclusion criteria. Out of these, 39 (20.2%) had no RAs while 154 had at least one. Pneumonia was diagnosed in 14.9% (95%CI 9.9-21.8%) and 0% (95%CI 0-11.2%) in those with and without respiratory abnormalities, respectively (p=0.005). History and physical exam to assess for RAs had a sensitivity of 100% (95% CI 82-100%) and a specificity of 23% (95% CI 17-30%) for the diagnosis of pneumonia. The sensitivity and specificity of CXR in this ED population of patients with SIRS is 65% (95% CI 43-83%) and 86% (95% CI 80-91%), respectively. Of the 39 patients with no RAs, there were 2 CXRs that were false positives for pneumonia and 37 CXRs that were true negatives. No patients in this group were ultimately diagnosed with a pneumonia. Conclusion: The prevalence of pneumonia is low in patients with SIRS without respiratory abnormalities in the ED. History and physical exam outperformed CXR in the ability to predict pneumonia in this population. Chest radiography may not be routinely indicated in the ED evaluation of patients with SIRS and no respiratory abnormalities.

Approximately 5% of all United States emergency department (ED) visits are for chest pain. At York Hospital coagulation tests are part of the "chest pain" order set utilized by physicians and nurses. Our objective was to assess the cost-effectiveness of routine coagulation testing of patients with chest pain in the ED. We conducted a retrospective chart review on a non-consecutive sample of patients evaluated for chest pain in the ED between the dates of August 1, 2010 and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with FFP or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or STEMI. We calculated the cost of the coagulation studies ordered on patients without the listed indications. Descriptive statistics were used for analysis. 761 of the 1849 charts for patients evaluated for chest pain during the study period were reviewed. Thirteen patients were excluded due to age <18, and an additional 8 patients left against medical advice before labs were drawn. Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of that 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. 315 patients of the 327 were tested with PT/INR ($19.00) and PTT ($33.50). 11 of the remaining 12 patients were tested with only a PT/INR, and 1 patient was tested with only PTT. One of the 327 patients (0.31%; 95%CI 0.05-1.7%) tested without indication had a clinically significant coagulopathy (INR >1.5, PTT >50 sec), but none (0%; 95%CI 0-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16,780. By our estimates, routine coagulation testing without indication for patients with chest pain in the York Hospital emergency department cost $165,000 annually. Coagulation testing on chest pain patients in the ED is not cost-effective and should not be routinely performed.