Background: The lack of evidence-based interventions to overcome patient refusal limits the success of emergency department (ED)-based HIV and hepatitis C virus (HCV) testing for diagnostic purposes or screening. We created a persuasive health communication intervention (PHCI) designed to overcome ED patient reluctance to accept HIV/HCV testing. In three pilot randomized controlled trials (pRCTs), we evaluated the performance of the PHCI when delivered by video or in-person by an HIV/HCV counselor, and as compared to a control condition video. Methods: Adult ED patients who declined HIV/HCV screening were enrolled. Participants were randomly assigned (1:1 allocation) in each pRCT as follows: pRCT 1: PHCI video vs. control condition video; pRCT 2: PHCI delivered in-person by HIV/HCV counselor vs. control condition video; and pRCT 3: PHCI delivered in-person by HIV/HCV counselor vs. the PHCI video. The primary outcome for each pRCT was acceptance of HIV/HCV testing post-intervention. Results: Acceptance of HIV, HCV or both tests post-intervention was: pRCT 1: PHCI video (n = 27) vs. control condition video (n = 28), 29.6% vs. 10.7%; p = 0.08; pRCT 2: PHCI delivered in-person by HIV/HCV counselor (n = 30) vs. control condition video (n = 30), 10.0% vs. 26.7%; p = 0.09; and pRCT3: PHCI delivered in-person by HIV/HCV counselor (n = 29) vs. the PHCI video (n = 29), 48.3% vs. 34.5%; p = 0.29. Conclusions: The results from these pRCTs are encouraging. ED patients who initially declined HIV/HCV testing can be persuaded instead to be screened for these infections. The PHCI, whether delivered in-person by an HIV/HCV counselor or video, is a promising intervention to encourage screening for these infections.

Education and technical training of lay persons to respond to mass casualty events with potential for life-threatening hemorrhagic injuries have been well documented with regards to programs such as Stop the Bleed. There is a limited amount of data, however, regarding the training of hospital-based physicians, in the use of tourniquets and other devices used to control massive hemorrhage in the event of a mass casualty event such as an active shooter or a natural disaster. In an effort to assess the effectiveness of training hospital-based physicians in massive up hemorrhage control utilizing tourniquets a pilot study was performed with a group of emergency medicine resident physicians.

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Selexipag is an oral selective prostacyclin IP receptor agonist indicated for treatment of pulmonary arterial hypertension (PAH). Data on its real-world safety and efficacy in Asians is lacking. Purpose We sought to evaluate the clinical characteristics, treatment regimens and outcomes of patients initiated on selexipag in a tertiary cardiac centre in Asia. Methods This was a retrospective study on all patients initiated on selexipag from January 2017 to December 2020. Baseline and follow up characteristics including demographics, functional status and clinical data were collected. Clinical outcomes evaluated included hospitalisation for PH related complications and all-cause mortality. Patients were risk stratified using the COMPERA 2.0 risk scores. Results A total of 36 PAH patients were treated with selexipag. At baseline, most patients were WHO functional class II or III (36.4% and 51.5% respectively), with a NT-proBNP of 1335 pg/ml (557 – 2918) and 6 minute walk test (6MWT) duration of 327.5 ±126.4 meters. Selexipag was initiated at 200mcg twice daily dosage for all except one patient (started at 200mcg once daily) and the maximum tolerated dose ranged from 200mcg twice daily to 1400mcg twice daily, with majority tolerating up to a dose of 600mcg twice daily (58.3%). Side effects were reported in 23 patients (63.9%), of which headache (27.8%), diarrhea (30.6%) or musculoskeletal symptoms (27.8%) were predominant. After a median follow up duration of 25.9 ± 23.1 months, selexipag was stopped in 20 patients (55.6%), of which eight patients were due to PAH progression requiring alternative therapy, and 12 patients due to side effects from selexipag. At baseline, patients were classified into low (8.3%), intermediate-low (30.6%), intermediate-high (33.3%) and high risk (27.8%) respectively. Patients who continued on selexipag at follow up showed no change (46.2%), improvement (15.4%) and deterioration (38.5%) in risk score. In the overall cohort of 36 patients, majority (75%) had at least one hospitalisation for PAH related complications and 15 patients (41.7%) demised. Conclusion In this real-world study, while selexipag was associated with a stable or improved PAH risk scores in majority of patients, there was a subset of patients with disease progression or intolerance to the medication. Further studies are warranted to identify patients who will benefit most from this therapy.

Abstract Funding Acknowledgements Type of funding sources: None. Introduction His bundle pacing (HBP) is associated with improved clinical outcomes compared to right ventricular apical pacing. However, it can be technically challenging and may result in prolonged fluoroscopy and procedural time. Purpose We sought to compare the feasibility of performing HBP with or without electrophysiology mapping (EP) system, focusing on evaluating acute procedural success, complication rates and short-term outcomes. Methods HBP patients at 3 hospitals were recruited between August 2018 to December 2020. HBP was performed with EP mapping system in 1 center, and without EP mapping in the other 2 centers. Acute procedural success was defined as either selective or non-selective His bundle capture with a threshold of less than or equal to 1.5V at 1ms at the end of procedure implantation. Results A total of 233 patients were recruited, of which HBP was performed with EP mapping in 77 patients (33.0%) and without EP mapping in 156 patients (67.0%). Both groups were similar in age (73.2 ± 11.0 years vs 75.3 ± 9.5 years, p = 0.125) and male sex (58.4% vs 48.1%, p = 0.136). There were more patients with ischemic heart disease (45.5% vs 22.4%, p < 0.01) and reduced left ventricular ejection fraction ≤ 40% (28.6% vs 10.9%, p < 0.01) in the group with EP mapping. The indications for HBP was for high-grade atrioventricular block (55.8%), sick sinus syndrome (35.6%) and cardiac resynchronization therapy (CRT) (8.6%). There were more patients who required CRT in the center with EP mapping (18.2% vs 3.8%, p < 0.01). HBP was successful in 39 patients (50.6%) with EP mapping and 93 patients (59.6%) without EP mapping (p= 0.382). The median R wave at implant was similar in both groups [4.0 (2.9 – 6.2) mV vs 4.3 (4.3 – 7.0) mV, p = 0.808]. Impedance at implant (607 ± 195 ohms vs 547 ± 166 ohms, p < 0.01) and selective His bundle bipolar threshold at implant [1.25 (0.75-1.75) V vs 0.7 (0.5 – 1.25) V, p = 0.01] was higher in patients with EP mapping while non-selective His bundle bipolar threshold at implant [1.75 (1.0 – 3.0) V vs 1.5 (0.9 – 2.2) V, p = 0.133] and paced QRS duration (116.4 ± 25.4 ms vs 114.4 ± 24.2 ms, p =0.655) were similar. There were no differences in procedural or fluoroscopy time between groups (111 ± 36.9 min vs 107 ± 40.7 min, p = 0.479; and 10.3 ± 8.9 min vs 12.1± 14.0 min, p = 0.328 respectively). There was a similar rate of acute procedural complications (5.2% vs 1.3%, p = 0.076) and patients requiring wound or lead revision (6.8% vs 1.9%, p = 0.115) after a median follow up duration of 205 days (67-397). The prevalence of new onset paroxysmal atrial fibrillation (11.7% vs 4.2%, p = 0.037) and all cause mortality (12.3% vs 3.2%, p = 0.029) was increased in patients who underwent HBP with EP mapping. Conclusion HBP in centers with or without EP mapping showed similar acute procedure success and complication rates. The use of EP mapping system was not shown to affect procedural or fluoroscopy duration.

To externally validate a risk-stratification tool—the Quick COVID-19 Severity Index (qCSI)—developed by Haimovich et al. to predict 24-hour respiratory decompensation in admitted patients with COVID-19. This was a retrospective observational cohort study of COVID-19 patients admitted from the emergency department between Feb 29, 2020 to Feb 1, 2021. The health care system is composed of a mix of 2 community and 4 academics EDs in a major metropolitan area. Patient demographics, vital signs, laboratory results were extracted from our institutional COVID-19 Data Warehouse. Following the convention of qCSI variables, respiratory rate (breaths/min), pulse oximetry (%), and oxygen flow rate (L/min) were used to calculate points between 0 to 12, with higher points associated with highly likelihood of respiratory decompensation within 24 hours. 35,696 COVID-19 patients were admitted via the emergency department during the study period. The mean qCSI was 1.73 (SD 1.82) for non-ICU admissions (n=34,647). The mean qCSI was 2.83 (SD 2.53) for ICU admission (n=1,049). As of the time of submission, ED treat and release patients, as well as decompensation results are pending. In this validation study of qCSI using a large system cohort of COVID-19 patients, qCSI appears to correlate strongly with clinical triage for admission decision to regular floor vs. ICU level care. Further analysis is needed to identify 24-hour respiratory decompensation after regular floor admission.

New York City Health + Hospitals/Elmhurst (EHC) in Queens, New York is one the most diverse populations in the United States of America and in the world. During the SARS-CoV-2 (Covid-19) pandemic, EHC was deemed the "epicenter of the epicenter" due to high rates of Covid-19 infection in the patient population and the disproportionate number of minorities affected by the virus. This study seeks to examine the effects of various social determinants of health on patient outcomes during the Covid-19 pandemic and to assess contributing factors which put these patients at increased risk.

Among patients admitted with coronavirus, vital signs recorded at initial emergency department (ED) presentation may inform outcomes. Our objective was to assess the impact of presenting vital signs on discharge after hospitalization, neurological sequelae, and hospital length of stay. We conducted a retrospective investigation at Elmhurst Hospital (Queens, New York) recognized as "the epicenter of the epicenter" of the 2020 coronavirus pandemic. Included were 2216 adult patients who tested positive for coronavirus. We studied vital signs recorded upon initial ED presentation including oxygen saturation, respiratory rate, temperature, heart rate, and blood pressure. We used multivariable logistic regression models to test for associations between presenting vital signs and discharge after hospitalization, neurological sequelae (cognitive/sensory/motor changes, new emotional instability, new onset seizures), and hospital length of stay. Upon abstract submission, data abstraction was still ongoing. Preliminary analysis suggested an association between higher initial oxygen saturation and increased odds of discharge after hospitalization (OR 1.108, 95% CI 1.004-1.223). It also suggested an association between higher initial respiratory rate and increased odds of neurological sequelae (OR 1.156, 95% CI 1.008-1.327). No association was observed between presenting temperature, heart rate, blood pressure, and outcomes. Among patients hospitalized with coronavirus, initial vital signs obtained at ED presentation provide useful prognostic information on short term outcomes.

New York City Health + Hospitals/Elmhurst located in Queens, New York, has one of the most diverse patient populations in the United States, and likely the world, and was deemed the "epicenter" of the Covid-19 pandemic in 2020. Given its unique population, high number of Covid-19 cases and growing concern that Covid-19 disproportionately affects minority patients, this study seeks to examine the correlation between ethnicity and time from symptoms onset to ED presentation to further understand this disparity.

Adverse cardiovascular events (ACVE) complicate > 16% of hospitalizations for acute drug overdose. Previously a risk prediction rule was derived for risk assessment of in-hospital ACVE in acute drug overdose patients, with >97% negative predictive value (NPV). Our aim was to externally validate the ACVE rule.

The CDC recommends hepatitis C (HCV) screening for adults born between 1945 and 1965 (birth cohort) and people who have engaged in high-risk activities. While HCV risk factors are known, the specific risk factor profiles of emergency department (ED) compared to other populations has not been documented. Furthermore, it is unclear if differences in risk exist between ED patients who agree to and decline testing or between those who test reactive (RE) or non-reactive (NR) for HCV antibodies (Ab). We sought to answer these questions by comparing risk factors among patients participating in a universal ED HCV screening program.

Residency programs struggle to provide meaningful milestone-based data that demonstrates measurable outcomes. Some programs have adopted clinical dashboards to display metrics, such as door-to-provider time, but often there is no explanation of how the resident should use the information to understand their performance. To the best of our knowledge, this is the first study to investigate the use of a resident clinical dashboard to integrate metrics and milestone assessments into ACGME mandated semi-annual evaluations. We hypothesized that our intervention would significantly improve resident and faculty satisfaction with the feedback provided and discussed during semi-annual evaluations. 62 EM residents from a single institution participated in this single blinded randomized controlled study. All residents were provided their own Dashboard via email with viewing instructions. The intervention group additionally received targeted feedback from faculty during their semi-annual evaluations using Key Performance Indicators (KPIs) from the Dashboard based on a synthesis of ACGME milestones, reportable quality metrics, and data registries such as the ACEP Clinical Emergency Data Registry. The control group received standard feedback from end-of shift evaluations and end-of-rotation evaluations only. Impact was determined via satisfaction forms. Data analysis followed intention-to-treat principles and included univariate statistics characterizing the data using both Wilcoxon-Mann-Whitney U and Kruskal-Wallis tests. 51 out of 62 residents (82%) completed satisfaction forms. Residents randomized to the intervention arm (n=28) who received targeted feedback using KPIs from the clinical dashboard felt significantly more strongly that their feedback was based on objective data (p=0.001); they were better able to identify their strengths when working clinically (p=0.05); and were overall more satisfied with the clinical feedback that they received (p=0.04). We found no significant differences in resident satisfaction when comparing the PGY years across all responses. Six faculty members also completed satisfaction forms for all 62 resident semi-annual encounters. For the encounters using the clinical dashboard, the faculty felt significantly more satisfied about the quantity of feedback given (p=0.0001); quality of feedback given (p=0.0003); that their feedback was based on objective data (p=0.0001); that they were able to identify the residents’ strengths (p=0.0001) and weaknesses (p=0.0001); and were overall more satisfied with the clinical feedback that they were able to provide (p=0.0001). Using a clinical dashboard to provide objective feedback during semi-annual evaluations appears to be more well-received by both residents and faculty compared to standard feedback, such as end-of-shift or end-of-rotation evaluations.

Best practices for mechanical ventilation favor lung protective ventilation (LPV) strategy with tidal volume settings of ≤8 mL/kg predicted body weight, especially for patients at risk for acute respiratory distress syndrome (ARDS). We aimed to identify patient factors associated with LPV usage for patients on mechanical ventilation in the emergency department (ED) and to measure the effect of ED crowding on LPV adherence. We conducted a retrospective chart review of all adult (≥18 years) mechanically ventilated patients in the ED who were admitted to the Medical Intensive Care Unit (ICU) between January 2012 and June 2015, at a single urban, academic tertiary-care center with a high volume ED. Patient characteristics, severity of illness (Mortality Probability Model-III on admission, MPM0-III; ED Lung Injury Prediction Score, ED-LIPS), and hospital clinical course were obtained through the electronic medical record via standardized chart abstraction. ED census variables were obtained at 5-minute intervals for the duration of mechanical ventilation in the ED and were averaged out by total patient counts, stratified by acuity and disposition. Ventilator settings were obtained at initial recording in the ED, final recording in the ED, and initial recording upon arrival to the ICU. Bivariate analysis and multivariate logistic regression models were utilized to predict likelihood of LPV adherence prior to departure from ED. During the study period, 455 patients (52.1% female) received mechanical ventilation in the ED. The study cohort had a mean age of 52.2±16.0 years, mean body mass index (BMI) of 28.1±8.5 and median ED time on mechanical ventilation of 3.8 hours (interquartile ratio, IQR, 2.3, 5.9). The mean ED-LIPS was 7.2±2.6 and of the 373 patients with an ED-LIPS ≥ 5, 31 (8.3%) were diagnosed with ARDS by ICU admission. Initial ED and final ED ventilator settings differed in 101 (22%) patients, whereas final ED and initial ICU ventilator settings differed in 296 (65.1%) patients. A significantly lower proportion of female patients were placed on LPV, compared to males (33.3 vs. 80.7%, p<0.001). Median BMI was significantly lower in patients placed on LPV (25.2, (IQR 21.7, 29.7) vs. 28.2 (IQR 24.2, 33.4); p<0.001). In the multivariate model controlling for patient factors, lower odds of LPV adherence were seen when there were higher proportions of ED patients requiring admission (OR 0.03; 95% CI 0.01, 0.83) and higher proportions of ED patients without a disposition decision (OR 0.05; 95% CI 0.01, 0.96). MPM0-III score, ED-LIPS, and ARDS diagnosis were not significantly associated with differential odds of LPV usage. Though lung protective ventilation is recommended for all intubated patients, ED patients often receive excessive tidal volumes and remain on unchanged settings from ED intubation through ICU admission. LPV was underutilized in female patients and those with higher BMIs, subgroups of patients for whom providers may be misestimating predicted body weight. To our knowledge, this study is the first to quantify the negative impact of ED crowding on the likelihood of a patient receiving LPV. Hospitals should focus on systematic efforts to increase LPV adherence in times of crowding, especially for patients at risk or with a diagnosis of ARDS.

With the recognition that inpatient costs continue to rise and the population is aging and will require greater health care services, the emergency department (ED) sits at the crossroads of multiple health care settings and plays a critical role in decisionmaking toward either inpatient or outpatient care and the transitions surrounding these decisions. GEDI WISE (Geriatric ED Innovations in care through Workforce, Informatics, and Structural Enhancements) is a CMMI Health Care Innovation Award program (1C1CMS331055-01).

Certain phenolic phytochemicals can kill cancer cells. Possible interference from antioxidants is a concern, and this issue has not been studied appreciably. Therefore, the effect of ascorbate and N-acetylcysteine on the ability of epigallocatechin gallate (EGCG) and curcumin to kill HCT116 colon cancer cells was examined. EGCG and curcumin each caused DNA damage in the cells. The DNA-damaging ability of EGCG, but not curcumin, was hindered by either ascorbate or NAC, which was also shown in HT29 and SW480 colon cancer cells. Also, iron chelators (deferoxamine and 2,2'- dipyridyl) inhibited the ability of EGCG, but not curcumin, to cause damage to the DNA in HCT116 cells. Interestingly, curcumin, but not EGCG, increased the expression of growth arrest and DNA damage-inducible gene 153 and also heme oxygenase-1, and this stress gene upregulation by curcumin was antioxidant-insensitive. With prolonged incubation of HCT116 cells with either EGCG or curcumin, cell shrinkage, membrane blebbing, apoptotic bodies, and chromatin condensation/fragmentation were observed. These morphological changes were not apparent in EGCG-treated cells that had been pretreated with either ascorbate or NAC. However, the ascorbate and NAC pretreatments did not prevent the occurrence of the morphological changes in curcumin-treated cells. Thus, these findings suggest that ascorbate and NAC interfere with the ability of EGCG, but not curcumin, to kill HCT116 cells. This basic knowledge may help to better plan and optimize strategies for chemoprevention or chemotherapy.