Post-intubation analgesia and sedation following succinylcholine vs. rocuronium in the emergency department.

BACKGROUND: Succinylcholine and rocuronium are the most commonly utilized neuromuscular blocker agents (NMBAs) for rapid sequence intubation (RSI) in the emergency department (ED). The duration of action of rocuronium is significantly longer (∼30 min) compared to succinylcholine (∼10 min) and previous studies have shown that patients receiving rocuronium are more likely to have longer time to sedation initiation following RSI. Furthermore, patients receiving rocuronium may be more likely to experience awareness with paralysis than those receiving succinylcholine. The primary goal for this study was to evaluate the association between NMBA use during RSI and post-intubation sedation and analgesia practices in the ED. METHODS: This was a retrospective, multicenter cohort study including patients 18 years and older that received succinylcholine or rocuronium during RSI in the ED between September 1, 2020 and August 31, 2021. Patients were excluded if they were intubated prior to ED arrival, experienced an out-of-hospital or in ED cardiac arrest, or received sugammadex within 60 min of rocuronium administration. Patients were screened in reverse chronological order until the targeted sample size was achieved and all data was abstracted from the electronic health record. The primary outcome was the time to initiation of analgesia or sedation. Secondary outcomes included dose of sedatives or analgesia administered at 30- and 60 min, and medications administered for post-intubation sedation or analgesia. FINDINGS: A total of 200 ED patients were included of which 100 received succinylcholine and 100 received rocuronium. There was no difference in the median time to initiation of analgesia or sedation between the succinylcholine and rocuronium groups (10 vs 8.5 min, p = 0.82) or in Kaplan-Meier cumulative probabilities (p = 0.17). At 60 min post-RSI, those receiving succinylcholine received significantly higher median doses of propofol (20 µg/kg/min vs. 10 µg/kg/min; p = 0.02) and fentanyl [100 µg vs. 84.2 µg; p = 0.02]. CONCLUSION: While no differences were observed in the time to initiation of post-intubation sedation or analgesia in ED patients receiving succinylcholine compared to rocuronium, differences in the intensity of post-intubation regimens was observed. Further investigation is needed to evaluate the adequacy of sedation following RSI in the ED.

Universal suicide screening in emergency departments across a large healthcare system.

BACKGROUND: Suicidal ideation is a common complaint in Emergency Departments (EDs) across the United States (US) and is an important preventable cause of death. Consequently, current Joint Commission guidelines require screening high-risk patients and those with behavioral health needs for suicide. Accordingly, we implemented universal suicide screening for all patients presenting to EDs in our healthcare system and sought to describe the characteristics of the identified "high-risk" patients. We also sought to determine whether universal suicide screening was feasible and what its impact was on ED length of stay (LOS). METHODS: All ED encounters in the healthcare system were assessed. Data were collected from February 1, 2020, through June 30, 2022. All patients aged 18 and over were screened using the Columbia Suicide Severity Rating Scale (C-SSRS) and categorized as no risk, low risk, moderate risk, and high risk. Encounters were then grouped into 'high risk" and "not high risk," defined as no, low, and moderate risk patients. Data collected included gender, discharge disposition, LOS, and insurance status. RESULTS: A total of 1,058,735 patient encounter records were analyzed. The "high risk" group (n = 11,359; 10.7%) was found to have a higher proportion of male patients (50.9 vs 43.7%) and government payors (71.6 vs. 67.1%) and a higher ED LOS [medians 380 min vs. 198 min] than the not high-risk group (p ≤0.001). Those with suicidal ideation comprised 0.73-1.58% of ED encounters in a given month. A secondary analysis of 2,255,616 ED encounter records from January 2019 - June 30, 2022, revealed that 40,854 (1.81%) encounters required 1:1 observation. The proportion of 1:1 observations in 2019, the year before implementation, was 1.91%. Using a non-inferiority margin of 25%, we found that the proportion of 1:1 patients in 2020, the year following implementation, was non-inferior to (no worse than) the previous year at 2.09% and decreased from 2021 to 2022 (1.69% and 1.57% respectively). CONCLUSION: Implementing universal suicide screening in all EDs within a healthcare system is feasible. The percentage of patients who screened high risk was under 5% of the overall ED population. While the median LOS was longer for "high-risk" patients than for the general ED population, it was not excessively so. Adequate staffing to properly maintain the safety of these patients is paramount.

Association between emergency department sepsis order set design and delay to second dose piperacillin-tazobactam administration.

BACKGROUND: Delay to first antibiotic dose in patients with sepsis has been associated with increased mortality. Second dose antibiotic delay has also been linked to worsened patient outcomes. Optimal methods to decrease second dose delay are currently unclear. The primary objective of this study was to evaluate the association between updating an emergency department (ED) sepsis order set design from one-time doses to scheduled antibiotic frequencies and delay to administration of second piperacillin-tazobactam dose. METHODS: This retrospective cohort study was conducted at eleven hospitals in a large, integrated health system and included adult patients treated in the ED with at least one dose of piperacillin-tazobactam ordered through an ED sepsis order set over a two year period. Patients were excluded if they received less than two doses of piperacillin-tazobactam. Midway through the study period, the enterprise-wide ED sepsis order set was updated to include scheduled antibiotic frequencies. Two patient cohorts receiving piperacillin-tazobactam were compared: those in the year before the order set update and those in the year post-update. The primary outcome was major delay, defined as an administration delay >25% of the recommended dosing interval, which was evaluated with multivariable logistic regression and interrupted time series analysis. RESULTS: 3219 patients were included: 1222 in the pre-update group and 1997 in the post-update group. The proportion of patients who experienced major second dose delay was significantly lower in the post-update group (32.7% vs 25.6%, p < 0.01; adjusted OR 0.64, 95% CI 0.52 to 0.78). No between-group difference was detected in the slope of monthly major delay frequency, but there was a significant level change (post-update change -10%, 95% CI -17.9% to -1.9%). CONCLUSIONS: Including scheduled antibiotic frequencies in ED sepsis order sets is a pragmatic mechanism to decrease delays in second antibiotic doses.

Computed Tomography Utilization for Patients Presenting with Chest Pain.

INTRODUCTION: Computed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain. METHODS: A retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 - April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain. RESULTS: There were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81-0.90). CONCLUSION: CT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.

Patients utilizing emergency medical services - Does facility type matter?

BACKGROUND: Emergency departments (EDs) play a critical role in the US healthcare system. As freestanding EDs (FSEDs) are integrated into the acute care landscape, local EMS providers are transporting to these facilities, which may be closer in proximity and provide faster turnaround times. We hypothesized that patients transported via EMS to a freestanding ED required fewer tests and are admitted less frequently than those transported to a HBED. Our objective was to compare testing frequency and admission rates between patients transported via EMS to a FSED vs. HBED. METHODS: This was a retrospective cohort study of all patients who presented within a large integrated hospital system via EMS to one of 10 HBEDs or one of 6 FSEDs between April 1, 2020 - May 1, 2021. Categorical variables are presented as frequencies and percentages and comparisons between groups were obtained using chi squared tests. Continuous variables are presented as mean and standard deviation and p-values comparing groups were obtained using t-tests. Multiple logistic regression was used to assess the effect of ED type on admission status, labs ordered, and testing performed. RESULTS: A total of 123,120 encounters were included in our study. Mean age at the FSEDs was 59.9 vs. 61.3 at the HBEDs. At the FSEDs 55.6% (n = 4675) were female vs. 53.0% (n = 60,809) at the HBEDs. At the FSEDs 82.0% (n = 6805) were White vs. 60.7% (n = 68,430) at the HBEDs. We found 50.0% (n = 3974) had Medicare at the FSEDs vs 50.9% (n = 55,372) at the FSEDs. At the FSEDs, 69.5% (n = 5846) had bloodwork vs. 82.4% (n = 94,512) at the HBEDs; 68.3% (n = 5745) had an x-ray at the FSEDs vs. 70.7% (n = 81,089) at the HBEDs; 40.1% (n = 3370) had a CT scan at the FSEDs vs. 44.9% (n = 51,503) at the HBEDs; and 40.6% (n = 3412) were admitted at the FSEDs vs. 56.1% (n = 64,355) at the HBEDs. After controlling for Charlson Comorbidity Index, acuity, age, gender, sex, insurance and race, patients in FSEDs were 35% less likely to be admitted as compared to HBEDs. CONCLUSION: Patients brought in via EMS to a FSED were less likely to have blood work, x-ray, or CT scan, and were less likely to be admitted to the hospital than those transported to a HBED.

Acute transverse myelitis progressing to permanent quadriplegia following COVID-19 infection.

As of January 2022, there have been over 350 million confirmed cases of COVID-19 in the world. The most common symptoms in those infected are fever, cough, malaise, and myalgia, however pulmonary, hematologic, gastrointestinal, renal, and neurologic complications have also been reported. Acute transverse myelitis (ATM) is an uncommon neurological syndrome characterized by acute or subacute spinal cord dysfunction that can lead to paresthesias, sensory and autonomic impairment, and even paralysis. Etiologies are often unclear; however, potential causes include infection, neoplastic, drug or toxin induced, autoimmune, and acquired. Treatment for ATM primarily consists of steroids and plasmapheresis, which often reverses any neurologic symptoms. ATM has rarely been reported as a complication of COVID-19 infections. A 43-year-old female presented to the emergency department for evaluation of progressive numbness and tingling in her legs ten days after developing upper respiratory symptoms from a COVID-19 infection. Physical examination and magnetic resonance imaging confirmed a diagnosis of ATM. During her hospital course, she experienced rapid progression of her paresthesias and developed complete loss of motor function in her upper and lower extremities. Within 48 hours after emergency department arrival, she required intubation due to worsening diaphragmatic and chest wall paralysis. Her treatment included a long-term steroid regimen and plasmapheresis, and unfortunately, she did not have any neurologic recovery. We present a very rare case of ATM progressing to complete quadriplegia following COVID-19 infection.

Reduced mortality and faster treatment in sepsis seen at freestanding vs. hospital-based emergency departments.

INTRODUCTION: Freestanding Emergency Departments (FEDs) have grown in number and understanding their impact on the healthcare system is important. Sepsis causes significant morbidity and mortality and identifying how FEDs impact sepsis morbidity and mortality has not been studied. The objective of this study was to determine if there is a difference in in-hospital mortality for sepsis patients who present initially to FEDs compared to a hospital-based ED. METHODS: This was a retrospective cohort of adult patients seen at a hospital-based ED or one of three FEDs within a large hospital system from 1/1/2018-10/31/2020. We included those who were diagnosed with sepsis, severe sepsis or septic shock and evaluated ED throughput measures, in-hospital mortality, and hospital length of stay. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviations or median and quartiles depending on distribution. Multiple logistic regression was fit to compare in-hospital mortality rates between the two groups. Variables controlled for included Charlson Comorbidity Index, race, gender, insurance, and sepsis severity. Wilcoxon rank sum tests were used to compare the time metrics. RESULTS: There were 1955 patients included in the study. Mean age of participants was 61.9 at the FEDs vs 63.7 at the HBED. Majority of the participants were white; 88.2% at the FED vs. 77.3% at the HBED; and male 49.0% at the FED vs. 51.1% at the HBED. Most patients had Medicare; 45.4% at the FED vs. 58.3% at the HBED. In-patient mortality rate was significantly lower for patients that presented to FEDs compared to HBED (95%CI 0.13-0.46) adjusted odds ratio 0.24. Time to IV fluids, time to lactate, time to blood cultures, time to ED disposition, ED LOS, time to arrival on the inpatient unit were all significantly lower for FEDs vs HBED (p < 0.05). CONCLUSION: Patients presenting to FEDs for sepsis, severe sepsis and septic shock had lower inpatient mortality, quicker treatment times, and were transferred and admitted to the hospital faster than patients seen at a HBED.

Improved hospital mortality rates after the implementation of emergency department sepsis teams.

INTRODUCTION: Sepsis is a leading cause of mortality with more than 700,000 hospitalizations and 200,000 deaths annually in the United States. Early recognition of sepsis is critical for timely initiation of treatment and improved outcomes. We sought to evaluate. in-hospital mortality rates of patients diagnosed with sepsis before and after implementation of emergency department (ED) sepsis teams. METHODS: This was a retrospective study of adult patients seen at a tertiary care ED diagnosed with sepsis and severe sepsis. Pre-implementation study time frame was 5/1/2018-4/30/2019 and post-implementation was 11/1/2019-9/30/2020. A six-month washout period was utilized after implementation of ED-based sepsis teams. Indications for sepsis team activation were: two systemic inflammatory response syndrome (SIRS) criteria with suspected infection or two SIRS with confirmed infection during workup. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation or median and quartiles depending on distribution. Multiple logistic regression compared mortality rates pre- and post-implementation while controlling for Charlson comorbidity index. Secondary objectives included comparing time metrics pre- and post-implementation. Student t-tests compared normally distributed variables and Wilcoxon rank sum tests compared non-normally distributed variables. RESULTS: There were 1188 participants included in the study; 553 before implementation of sepsis teams and 635 after implementation. Mean age of participants was 64 years. Patients were 74.7% white and 22.6% black. Medicare was the most common health insurance (59%). Mortality rates were significantly lower post-implementation of sepsis teams compared to pre-implementation with an adjusted odds ratio of 0.472, (95%CI, 0.352-0.632). ED LOS (95%CI (-67.2--11.3), hospital LOS (95%CI, -1.0--0.002) and time to lactic acid (95%CI, -10.0- -3.0) and antibiotics (95%CI, -29.0--11.0) were all significantly lower after implementation. CONCLUSION: Implementation of ED sepsis teams decreased inpatient hospital mortality rates, ED length of stay and hospital length of stay.

Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments.

BACKGROUND: Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States. METHOD: We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital. RESULTS: Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals. CONCLUSION: Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.

The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED.

BACKGROUND: Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS: This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS: 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS: A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool.

INTRODUCTION: The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. METHODS: A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. RESULTS: The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. CONCLUSION: A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.

Same provider, different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments.

BACKGROUND: Patient satisfaction scores have become quality benchmarks for hospitals, are publicly reported, and are often tied to financial incentives. We determined whether patient satisfaction scores for individual emergency medicine providers varied according to the clinical setting. METHODS: We obtained patient satisfaction survey results from January 1, 2018 to December 31, 2018 for patients treated at 6 freestanding (FED) and 11 hospital-based emergency departments (HBED). Differences in mean score by ED facility were tested for significance. Mean score differences with 95% confidence intervals are presented. Univariate and multivariable logistic regression analysis was conducted to predict the odds of receiving different scores by type of ED facility and adjusted for patient and provider demographics and ED length of stay. RESULTS: Sixty-six providers with 3743 total surveys were analyzed: FED (n = 1974) and HBED (n = 1769). Overall satisfaction scores were higher for FED compared to HBED surveys 1.13 [95% CI, 1.0-1.3]. In multivariable logistic regression, we found patients seen at the FEDs were 42% more likely to rate providers courtesy as "very good" compared to patients seen at a HBED [OR: 1.42, 95% CI (0.94-2.15)]. Similarly, patients from FEDs showed increased likelihood to rate providers as "very good" for keeping patients informed about treatment [OR: 1.70, 95% CI (1.21-2.39)], took time to listen to patients [OR: 1.66, 95% CI (0.72-1.60)] and concerned for patient's comfort [OR: 1.54, 95% CI (1.12-2.12)]. CONCLUSION: Individual providers, who practice at both types of facilities, consistently received higher satisfaction ratings from patients at FEDs compared to HBEDs.

Evaluation of a health system-wide pharmacist-driven emergency department laboratory follow-up and antimicrobial management program.

BACKGROUND: Emergency Department (ED) follow-up programs ensure that cultures, laboratory studies, and empiric antimicrobials are appropriately managed post-discharge. We sought to provide a comprehensive assessment of a pharmacist-driven laboratory follow-up process in a large, integrated health system. METHODS: A retrospective, observational review of 13 EDs was conducted. Patients were included if they had a laboratory study sent from the ED between December 1, 2017 and May 31, 2018 that did not result while the patient was in the ED. Microbiology results analyzed were urine, wound, respiratory, stool, throat, bacterial vaginosis, vaginal candidiasis, and sexually transmitted infections (STI). Examples of laboratory results assessed were metabolic panels and drug levels. The primary objective was to quantify the number of interventions made by pharmacists. RESULTS: During a 6-month period, pharmacists reviewed 9107 microbiology results and 6211 laboratory results. The majority of results were urine cultures (3998, 50.6%) followed by STI results (1198, 15.2%). Of 7663 encounters, 39.8% required interventions and/or follow-up with a total of 3049 interventions made and 3333 patients educated. The most common interventions were initiation of therapy (1629, 53.4%), change in medication (505, 16.6%), and follow-up with a clinician (322, 10.6%). Pharmacists reviewed microbiology results and completed interventions in a median of 25.3 h from the time the result was received in the electronic health record. CONCLUSION: Almost 40% of ED encounters required an intervention after discharge. A pharmacist led laboratory follow-up program is an important adjunct to facilitating stewardship and culture management in the ED.

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.

OBJECTIVE: Overdose from opioids has reached epidemic proportions. Large healthcare systems can utilize existing technology to encourage responsible opioid prescribing practices. Our study measured the effects of using the electronic medical record (EMR) with direct clinician feedback to standardize opioid prescribing practices within a large healthcare system. METHODS: This retrospective multicenter study compared a 12 month pre- and post-intervention in 14 emergency departments after four interventions utilizing the EMR were implemented: (1) deleting clinician preference lists, (2) defaulting dose, frequency, and quantity, (3) standardizing formulary to encourage best practices, and (4) creating dashboards for clinician review with current opioid prescribing practices. Outlying clinicians received feedback through email and direct counseling. Total number of opioid prescriptions per 100 discharges pre- and post-intervention were recorded as primary outcome. Secondary outcomes included number of prescriptions per 100 discharges/clinician exceeding 3-day supply (defined as 12 tablets), number exceeding 30 morphine equivalent daily dose (MEDD)/day, and number of non-formulary prescriptions. RESULTS: There were >700,000 discharges during pre- and post-intervention periods. Percentage of total number opioid prescriptions per 100 discharges decreased from 14.4% to 7.4%, a 7.0% absolute reduction, (95% CI,6.9%-7.2%). There was a 5.9% to 0.7% reduction in prescriptions exceeding 3-days, (95% CI, 5.1%-5.3%), a 4.3% to 0.3% reduction in prescriptions exceeding 30 MEDD, (95% CI, 3.9%-4.0%), and a 0.3% to 0.1% reduction in non-formulary prescriptions, (95% CI, 0.2%-0.3%). CONCLUSIONS: A multi modal approach using EMR interventions which provide real time data and direct feedback to clinicians can facilitate appropriate opioid prescribing.

Differences in patient population and length of stay between freestanding and hospital-based emergency departments.

BACKGROUND: Freestanding emergency departments (FEDs) represent over 10% of emergency departments (EDs) in the United States. Little is known about differences in encounter characteristics. We compared ED length of stay (LOS) clinical demographics, method of arrival, acuity level, and patient disposition for encounters to FEDs vs. hospital-based EDs (HBEDs). METHODS: A multi-center retrospective analysis was performed. Study sites included 6 FEDs and 13 HBEDs from 10/1/2017 to 9/30/2018. Data was abstracted from ED records and discharge summary within the electronic health record. Descriptive statistics were reported with prevalence (95% Confidence Interval [CI]) for categorical variables and mean (standard deviation [SD]) for continuous variables. Multivariable linear regression assessed the relationship between ED facility (FEDs vs. HBEDs) and ED length of stay (LOS). RESULTS: 1,263,297 encounters were analyzed. Mean ED LOS was shorter at FEDs (146.62 min (±97.04)) vs. HBED (249.70 min (+287.50)). Nine percent of FED encounters arrived via EMS vs. 21% at the HBEDs. FEDs saw 5.47% emergency severity index (ESI) level 2 vs. 13.76% at the HBEDs. Medicaid and Medicare patients were more prevalent in HBEDs (64.2%) than in FEDs (50.6%). FEDs admitted 13% of patients and HBEDs 27%. All results were significant (p < 0.001). After adjusting for potential confounding variables, patients utilizing FEDs had 16.2% shorter ED LOS vs. HBEDs (ß = -0.18 [95% CI: -0.18 to -0.17]). CONCLUSION: Overall ED LOS was significantly less for FED vs. HBED patients. Acuity level, insurance status, method of arrival, and patient disposition were significantly different at FEDs vs. HBEDs.

Impact of an individual plan of care for frequent and high utilizers in a large healthcare system.

INTRODUCTION: "Frequent or High Utilizers" are significant stressors to Emergency Departments (EDs) and Inpatient Units across the United States (US). These patients incur higher healthcare costs with ED visits and inpatient admissions. Our aims were to determine whether implementation of individualized care plans (ICPs) could 1) reduce costs, 2) reduce inpatient length of stay (LOS), and 3) reduce ED encounters throughout a large healthcare system. METHODS: 13 EDs were included including academic, community, Free-standing and pediatric EDs. Data was collected from January 1, 2014 through December 31, 2017. ICPs were created for high ED utilizers, as recommended by staff input through multidisciplinary care committees at each site. The ICP consisted of 1) specific symptom-related information with approaches in management, 2) recent assessment from specialists, 3) social work summary, and 4) psychiatry summary. A Best Practice Alert was placed in the electronic medical record that could be seen at all hospitals within the system. ICP's were updated annually. RESULTS: 626 ICPs were written; 452 initial ICPs and 174 updates. The 452 ICP patients accounted for 23,705 encounters during the four-year period; on average, an ICP patient visited the ED 52 times (14.75 encounters/year). Overall indirect and direct costs decreased 42% over first 6 months, inpatient LOS improved from 1.9 to 0.97 days/month, and ED encounters decreased from 1.96 to 1.14. All cost and LOS data significantly improved at 24 months post-ICP inception. CONCLUSION: Implementation of individualized care plan can reduce cost, inpatient LOS, and ED encounters for high utilizers.