The impact of a point-of-care visual clinical decision support tool on admissions for cellulitis in the University of Maryland medical system.

Introduction: Cellulitis is commonly diagnosed in emergency departments (EDs), yet roughly one third of ED patients admitted for presumed cellulitis have another, usually benign, condition instead (eg, stasis dermatitis). This suggests there is an opportunity to reduce health care resource use through improved diagnosis at the point of care. This study seeks to test whether a clinical decision support (CDS) tool interoperable with the electronic medical record (EMR) can reduce inappropriate hospital admissions and drive more appropriate and accurate care. Methods: This study was a trial of an EMR-interoperable, image-based CDS tool for evaluation of ED patients with suspected cellulitis. At the point of assigning a provisional diagnosis of cellulitis in the EMR, the clinician was randomly prompted to use the CDS. Based on the patient features entered into the CDS by the clinician, the CDS provided the clinician a list of likely diagnoses. The following were recorded: patient demographics, disposition and final diagnosis of patients, and whether antibiotics were prescribed. Logistic regression methods were used to determine the impact of CDS engagement on our primary outcome of admission for cellulitis, adjusted for patient factors. Antibiotic use was a secondary end point. Results: From September 2019 to February 2020 (or 7 months), the CDS tool was deployed in the EMR at 4 major hospitals in the University of Maryland Medical System. There were 1269 encounters for cellulitis during the study period. The engagement with the CDS was low (24.1%, 95/394), but engagement was associated with an absolute reduction in admissions (7.1%, p = 0.03). After adjusting for age greater than 65 years, female sex, non-White race, and private insurance, CDS engagement was associated with a significant reduction of admissions (adjusted OR = 0.62, 95% confidence interval (CI): 0.40-0.97, p = 0.04) and antibiotic use (Adjusted OR = 0.63, 95% CI: 0.40-0.99, p = 0.04). Conclusions: CDS engagement was associated with decreased admissions for cellulitis and decreased antibiotic use in this study, despite low levels of CDS engagement. Further research should examine the impact of CDS engagement in other practice environments and measure longer-term outcomes in patients discharged from the ED.

Illicit Fentanyl Exposure Among Victims of Violence Treated at a Trauma Center.

INTRODUCTION: Opioid overdoses and violent injury are leading causes of death in the United States, yet testing for novel opioids like fentanyl remains uncommon. The purpose of this investigation is to characterize a population of victims of violence who test positive for illicit fentanyl. METHODS: Retrospective cohort study of patients treated at a level-one trauma center between January 31, 2019 and February 21, 2020. Data were extracted from the electronic medical record. Subjects were included if they had an encounter diagnosis for a violent or intentional injury, using the International Classification of Diseases, v10 (X92-Y09). We excluded patients who received licit fentanyl as a part of their care before testing. Those who tested positive for fentanyl exposure on our standard hospital urine drug screen were considered to have been exposed to illicit fentanyl. Those testing negative for fentanyl were considered controls. RESULTS: Of the 1132 patients treated for intentional injuries during the study period, 366 were included in the study (32.3%). Of these, 133 (36.3%) subjects were exposed to illicit fentanyl prehospital. There were no demographic differences between cases and controls. Cases had a lower GCS voice score on arrival (median = 4, interquartile range [IQR] = 4-5 versus median = 5, IQR = 4-5, P = 0.02), higher rates of ventilator usage (32.3% versus 21.5%, P = 0.02), and more intensive care unit admissions (27.1% versus 12.0%, P = 0.005). More than half of cases tested negative for opiates (78/133, 58.6%). Cases had more trauma center encounters (26.3% had ≥2 visits versus 15.5%). CONCLUSIONS: Exposure to illicit fentanyl was common among victims of violence in this single-center study. These patients are at increased risk of being admitted to intensive care units and repeated trauma center visits, suggesting fentanyl testing may help identify those who could benefit from violence prevention and substance abuse treatment.

58-year-old Male with a Headache, Hand Numbness, and Phantosmia.

INTRODUCTION: A 58-year-old male presents to the emergency department with headache, hand numbness, and phantosmia. CASE PRESENTATION: Magnetic resonance imaging showed multiple acute and early subacute lesions involving the cortex and subcortical white matter of the left frontal lobe, left parietal lobe, left temporal lobe, left caudate, and left putamen. DISCUSSION: This case takes the reader through the subtle findings that led to the diagnosis and ultimately to treatment.

57-year-old Female with Unusual Left-arm Movements.

INTRODUCTION: A 57-year-old, right-hand dominant female presented to the emergency department striking herself with her left hand. CASE PRESENTATION: The astute medical staff looked beyond a behavioral health etiology. A detailed history, physical examination, and workup reveals the fascinating final diagnosis. DISCUSSION: This case takes the reader through the differential diagnosis and systematic workup of uncontrolled limb movements with discussion of the studies which ultimately led to this patient's diagnosis.

Early Prediction of Intensive Care Admission in Emergency Department Patients With Asthma.

BACKGROUND: Emergency physicians must choose whether patients with asthma are admitted to a hospital ward or a higher level of care, such as an intermediate care unit (IMC) or intensive care unit (ICU). OBJECTIVE: This study aimed to determine which variables, available early during emergency department (ED) visits, are associated with IMC/ICU admission. METHODS: In this retrospective chart review (records from 2015-2018), two trained abstractors, blinded to study hypothesis, abstracted data on predictor variables and disposition (ward vs. IMC/ICU). Predictor variables were defined explicitly and abstracted from the periods of ED arrival and after treatment with 7.5 mg nebulized albuterol. Distress was defined as tripod positioning or speaking in broken sentences. "Arrival" and "after treatment" scoring systems were derived based on adjusted odds ratios (aOR) for predictor variables. We performed analyses using SASⓇ, version 9.4 (SAS Institute). RESULTS: Among 273 patients, 105 required admission to an IMC/ICU. At presentation, distress (aOR 2.1, 95% confidence interval [CI] 1.1-3.9), room air SpO2 ≥95% (aOR 0.29, 95% CI 0.14-0.62), respiratory rate > 20 breaths/min (aOR 1.9, 95% CI 1.0-3.3), and retractions (aOR 1.9, 95% CI 1.1-3.3) were associated with IMC/ICU admission. After initial bronchodilator therapy, heart rate > 120 beats/min (aOR 7.1, 95% CI 2.0-25), room air SpO2 ≥ 95% (aOR 0.15, 95% CI 0.07-0.34), and noninvasive ventilation (aOR 6.5, 95% CI 2.5-17) were associated with IMC/ICU admission. Both scoring systems stratified risk of IMC/ICU admission into low-risk (9-10%) and high-risk (70-100%) groups. CONCLUSIONS: Combinations of predictor variables, available early in a patient's stay, stratify risk of admission to an IMC/ICU bed.

Coding Disparity and Specificity during Emergency Department Visits after Transitioning to the Tenth Version of the International Classification of Diseases.

The purpose of this study was to examine coding changes using the International Classification of Diseases (ICD) after the transition from ICD-9 to ICD-10. We studied a national cohort of emergency department visits from the Veterans Health Administration (VHA) before and after the transition, focusing on coding disparity and coding specificity. The cohort accounted for 2 million emergency department visits by 1.2 million patients. There were no statistical differences between the groups with respect to demographics, comorbidities, diagnoses, or use of medical services. While ICD-10 offered significantly more codes as well as more specific coding options, the ICD-10 encounters continued to use a small number of codes, were less likely to use multiple codes, and did not consistently exploit the more unique codes to create more specific diagnoses. These findings within the VHA system corresponded to similar challenges that have been documented with Medicare claims and in the private sector.

The actual, long-term cost of intentional injury care among a cohort of Maryland Medicaid recipients.

BACKGROUND: Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients. METHODS: Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury. RESULTS: Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study. CONCLUSION: The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states. LEVEL OF EVIDENCE: Economic and Value Based Evaluations; level III.

73-year-old Female with Syncope and Motor Vehicle Collision.

INTRODUCTION: Patients with traumatic injuries can be difficult to assess, and their evaluation often evolves in the emergency department (ED). We describe how an ED attending physician member developed a differential diagnosis for this presentation, arrived at a suspected diagnosis, and what test he proposed to prove his hypothesis. CASE PRESENTATION: This clinicopathological case presentation details the initial assessment and management of a 73-year-old female who presented to the ED following a motor vehicle collision precipitated by a syncopal episode. CONCLUSION: The final surprising diagnosis is then revealed.

55-year-old Male with Fatigue.

This clinicopathological case presentation from the University of Maryland details the initial assessment and management of a 55-year-old, dialysis-dependent man with fatigue. We present how one of our emergency medicine faculty develops her differential when faced with this complaint. She describes how she arrives at the suspected diagnosis and the test she believes is needed to prove her hypothesis. The final surprising diagnosis is then revealed.

19-year-old Woman with Intermittent Weakness.

INTRODUCTION: Systemic weakness is a common chief complaint of patients presenting to the emergency department (ED). A well thought out approach to the assessment and workup of these patients is key to diagnostic accuracy and definitive therapy. CASE PRESENTATION: In this case, a 19-year-old female presented to the ED with generalized weakness and near syncope. She had global weakness in her extremities and multiple electrolyte abnormalities. DISCUSSION: This case takes the reader through the differential diagnosis and evaluation of a patient with weakness and profound electrolyte derangements. It includes a discussion of the diagnostic studies and calculations that ultimately led to the patient's diagnosis.

Masking for COVID-19 Is Associated with Decreased Emergency Department Utilization for Non-COVID Viral Illnesses and Respiratory Conditions in Maryland.

BACKGROUND: Masking, which is known to decrease the transmission of respiratory viruses, was not widely practiced in the United States until the coronavirus disease 2019 (COVID-19) pandemic. This provides a natural experiment to determine whether the percentage of community masking was associated with decreases in emergency department (ED) visits due to non-COVID viral illnesses (NCVIs) and related respiratory conditions. METHODS: In this observational study of ED encounters in a 11-hospital system in Maryland during 2019-2020, year-on-year ratios for all complaints were calculated to account for "lockdowns" and the global drop in ED visits due to the pandemic. Encounters for specific complaints were identified using the International Classification of Diseases, version 10. Encounters with a positive COVID test were excluded. Linear regression was used to determine the association of publicly available masking data with ED visits for NCVI and exacerbations of asthma and chronic obstructive pulmonary disease (COPD), after adjusting for patient age, sex, and medical history. RESULTS: There were 285,967 and 252,598 ED visits across the hospital system in 2019 and 2020, respectively. There was a trend toward an association between the year-on-year ratio for all ED visits and the Maryland stay-at-home order (parameter estimate = -0.0804, P = .10). A 10% percent increase in the prevalence of community masking was associated with a 17.0%, 8.8%, and 9.4% decrease in ED visits for NCVI and exacerbations of asthma exacerbations and chronic obstructive pulmonary disease, respectively (P < .001 for all). CONCLUSIONS: Increasing the prevalence of masking is associated with a decrease in ED visits for viral illnesses and exacerbations of asthma and COPD. These findings may be valuable for future public health responses, particularly in future pandemics with respiratory transmission or in severe influenza seasons.

A spatio-temporal Bayesian model to estimate risk and evaluate factors related to drug-involved emergency department visits in the greater Baltimore metropolitan area.

The ongoing opioid overdose epidemic in the United States presents a major public health challenge. Opioid-involved morbidity, especially nonfatal emergency department (ED) visits, are a key opportunity to prevent mortality and measure the extent of the problem in the local substance use landscape. Data on the rate of ED visits is normally distributed by federal agencies. However, state- and substate-level rates of ED visit demonstrate significant geographic variation. This study uses an ongoing sample of ED visits from four hospitals in the University of Maryland Medical System from January 2016 to December 2019 to provide locally sensitive information on ED visit rates and risk for drug-related health outcomes. Using exploratory spatial data analysis and spatio-temporal Bayesian models, this study analyzes both the frequency and risk of heroin-, methadone-, and cocaine-involved ED visits across the greater Baltimore Maryland area at the Zip Code Tabulation Area-level (ZCTA). The Global Moran's I for total heroin-, methadone-, and cocaine-involved ED visits in 2019 was 0.44, 0.56, and 0.53, demonstrating strong positive spatial autocorrelation. Spatio-temporal Bayesian models indicated that ZCTA with a higher score in a deprivation index, with a higher share of Centers for Medicare Services claims, and adjacent to a sampled UMMS hospital had an increased risk of ED visits, with variation in the magnitude of this increased risk depending on the drug-demographic strata. Modeled disease risk surfaces - including posterior median risk and posterior exceedance probabilities - showed distinctly different risk surfaces between the substances of interest, probabilistically identifying ZCTA with a lower or higher risk of ED visits. The modeling approach used a sample of ED visits from a larger health system to estimate recent, locally sensitive drug-related morbidity across a large metropolitan area.

Comparison of 4 tests' utility for predicting need for emergency department care in patients with alcohol-related complaints.

INTRODUCTION: Intoxication is a common presenting complaint in emergency departments (ED), but many patients with intoxication do not need emergency care. Three screens (BLINDED, Brown, and San Francisco) attempt to determine which intoxicated patients can be triaged to a lower level of care. METHODS: Observational multi-center cohort study of patients presenting to one of three ED with complaints consistent with acute intoxication. When a qualifying patient was brought to the emergency department, a team member interviewed the triaging provider. Interviews covered all three screens and the provider's gestalt. Receiver operating curve (ROC) analysis was used to determine which screen performed best. Cases were reviewed to determine need for emergency care. RESULTS: Of the 199 subjects studied, 91% (181/199) were male and were 50 years old on average (SD = 12 years). Of the 55 subjects tested (28%), their average alcohol level was 251 mg/dL (SD = 146 mg/dL). Only 117 subjects (59%) had complete information for inclusion in the final comparison of screens. Provider gestalt performed best (AUC = 0.69), but there were no meaningful differences between any of the screens (AUC = 0.62-0.66, p > 0.05 for all comparisons). Inability to sit up was sensitive for needing emergent care (88%), but it was non-specific (17%). Similarly, signs of trauma were specific (99%) for ED care, but insensitive (18%). CONCLUSIONS: The three formal screens and provider gestalt performed similarly.

40-year-old Female with Sudden Onset Dyspnea.

A 40-year-old female presented to the emergency department (ED) after the acute onset of dyspnea. The patient was tachypneic with accessory muscle usage and diffuse wheezing on initial examination. Despite aggressive treatment, the patient deteriorated and was intubated. This case takes the reader through the differential diagnosis and systematic workup of a patient presenting to the ED with dyspnea and arrives at the unexpected cause for this patient's presentation.

Emergency Department Asthma "Spacing Trials": Institutional Variability and Time Cost.

BACKGROUND: Some admitting physicians request a medication-free interval ("spacing trial") in the emergency department (ED) to determine whether a patient with an acute exacerbation of asthma can be safely admitted to a hospital ward bed, where bronchodilators are only available every 4 h. OBJECTIVE: Our objectives were to estimate the frequency of ED spacing trials in different hospitals and their associated time cost. METHODS: This multicenter retrospective cohort study examined patients admitted for asthma from 2015 to 2018. We included all university records and a random sample of records from two community hospitals in the same urban area. Two team members abstracted data from each record using recommended methods, with group consensus to resolve differences. Proportion confidence intervals were calculated using normal binomial approximation. We calculated mean differences in ED stay associated with spacing trials, using multivariable linear regression to adjust for age, hospital type, history of intubation, initial pulse, initial respiratory rate, initial signs of distress. RESULTS: We collected data from 274 patients in the university hospital, and 71 and 70 cases from the community hospitals. An explicit spacing trial was noted in 52 of 274 (19%) university hospital records vs. 3 of 141 (2%) community hospital records, with a difference of 17% (95% confidence interval [CI] 11-23%). Delayed patient decompensation occurred in 3%, with no difference between hospitals. Spacing trials were associated with an adjusted mean of 159 min (95% CI 102-217 min) increase in ED stay. CONCLUSIONS: The practice of spacing varies widely between hospitals and is associated with substantial delay without an apparent benefit.

40-year-old Male with a Headache and Altered Mental Status.

A 40-year-old man presents to the emergency department with headache, nausea and paresthesias, with subsequent fever and mental status change. Magnetic resonance imaging showed increased fluid-attenuation inversion recovery signal involving multiple areas of the brain, including the pons. This case takes the reader through the differential diagnosis of rhombencephalitis (inflammation of the hindbrain) with discussion of the unanticipated ultimate diagnosis and its treatment.

20-year mortality after discharge in a cohort of 1,099 former trauma inpatients with and without substance use disorders.

INTRODUCTION: Psychoactive substance use disorders (SUDs) are common in trauma patients and substance use has become a leading cause of death in the United States. The purpose of this study is to examine the impact of a lifetime SUD and SUD characteristics (substance used, current SUD versus in remission from dependence, etc.) on the long-term survival of trauma patients. METHODS: Cohort study of consecutive adult trauma inpatients who were discharged alive from a level-one trauma center (1994-1996). The presence of lifetime SUD was determined at the time of admission by the Structured Clinical Interview for the Diagnostic and Statistical Manual III-R. Mortality follow-up through the end of 2017 was obtained by linking patients to a national database of death certificates. Cox proportional hazards analysis was used to determine the association of lifetime SUD and death after adjusting for age and tobacco use. RESULTS: 1,220 patients were approached, 1,118 consented to participate, and 1,099 had personal identifiers for matching. 789 (71.8%) of subjects were men, 596 (54.2%) had lifetime SUDs, and 325 (29.6%) died. Injury was the most common cause of death (24.6%, 80/325), with poisonings (40.0%, 32/80) being the most common injury-related cause of death. Compared to those without a lifetime SUD, lifetime SUD was associated with increased all-cause mortality (adjusted hazard ratio [HRadj]=1.83; 95% CI, 1.4 to 2.4), injury death (HRadj=2.47; 95% CI: 1.4 to 4.2), and fatal opioid overdose (HRadj=12.96; 95% CI, 1.7 to 100.4)(p ≤ 0.01 for all HRadj). CONCLUSIONS: The presence of a lifetime SUD was associated with early death, particularly from reinjury, in trauma patients. It is important to address a patient's SUD during admission to decrease their chances of dying after discharge, especially due to injury-related causes.

36-year-old Male with Syncope.

CASE PRESENTATION: A 36-year-old incarcerated male presented to the emergency department (ED) after an episode concerning for syncope. The patient had nystagmus and ataxia on initial examination. DISCUSSION: There is a broad differential diagnosis for syncope, and for patients presenting to the ED we tend to focus on cardiogenic and neurologic causes. This case takes the reader through the differential diagnosis and systemic work-up of a patient presenting to the ED with syncope.

55-year-old Male with Exertional Dyspnea.

INTRODUCTION: Dyspnea is a common presenting complaint for many patients in the emergency department. CASE PRESENTATION: A 55-year-old man with type I diabetes presented to the emergency department with one month of intermittent palpitations and dyspnea. His lungs were clear to auscultation, and his chest radiograph was normal. DISCUSSION: This case takes the reader through the differential diagnosis and systematic work-up of dyspnea with discussion of the diagnostic study, which ultimately led to this patient's diagnosis and successful treatment.

National Early Warning Score Is Modestly Predictive of Care Escalation after Emergency Department-to-Floor Admission.

BACKGROUND: Decompensation on the medical floor is associated with increased in-hospital mortality. OBJECTIVE: Our aim was to determine the accuracy of the National Early Warning Score (NEWS) in predicting early, unplanned escalation of care in patients admitted to the hospital from the emergency department (ED) compared to the Shock Index (SI) and the quick Sepsis-Related Organ Failure Assessment (qSOFA) score. METHODS: We conducted a retrospective cohort study of patients admitted directly from the ED to monitored or unmonitored beds (November 9, 2015 to April 30, 2018) in 3 hospitals. Interhospital transfers were excluded. Patient data, vital status, and bed assignment were extracted from the electronic medical record. Scores were calculated using the last set of vital signs prior to leaving the ED. Primary endpoint was in-hospital death or placement in an intermediate or intensive care unit within 24 h of admission from the ED. Scores were compared using the area under the receiver operating curve (AUROC). RESULTS: Of 46,018 ED admissions during the study window, 39,491 (85.8%) had complete data, of which 3.7% underwent escalation in level of care within 24 h of admission. NEWS outperformed (AUROC 0.69; 95% confidence interval [CI] 0.68-0.69) qSOFA (AUROC 0.63; 95% CI 0.62-0.63; p < 0.001) and SI (AUROC 0.60; 95% CI 0.60-0.61; p < 0.001) at predicting unplanned escalations or death at 24 h. CONCLUSIONS: This multicenter study found NEWS was superior to the qSOFA score and SI in predicting early, unplanned escalation of care for ED patients admitted to a general medical-surgical floor.