Impact of Implementation of a New Weapons Screening at an Urban Emergency Department.

BACKGROUND: Violence in the emergency department (ED) setting is well documented in medical literature. Weapons can be used to cause significant injury or mortality, although there is a paucity of literature on weapons and weapons screening in the ED. OBJECTIVES: The purpose of this study was to assess the impact of initiating a weapons screening process on the identification and removal of weapons. METHODS: Multiple aspects of a weapons screening program were evaluated at 2 and 6 months prior to and after a weapons screening protocol was initiated at an urban ED. In the Pre-Screen periods, only patients primarily seeking care for mental health were screened prior to entry. In the Post-Screen periods, all patients and visitors were screened with walk-through magnetometers or wand metal detectors, and additional screening checks were initiated. The number of individuals screened and numbers of weapons found were measured. Descriptive statistics comparing Pre- and Post-Screen periods were performed. RESULTS: Prior to the new screening process, 511 and 1701 patients primarily seeking care for mental health were screened, with 15 and 103 weapons confiscated at 2 and 6 months, respectively. After the screening process was initiated, 13,149 and 43,321 ED patients and visitors were screened, with 194 and 567 weapons confiscated at 2 and 6 months, respectively. Persons screened increased by 25-fold at both 2 and 6 months after implementing the screening process. Weapons confiscated increased approximately 13-fold and sixfold at the respective 2- and 6-month Pre- and Post-Screen periods, respectively. CONCLUSION: Implementation of weapons screening significantly increased the number of weapons identified and confiscated prior to entry in the ED by patients and visitors.

Heat Waves and Emergency Department Visits Among the Homeless, San Diego, 2012-2019.

Objectives. To determine the effect of heat waves on emergency department (ED) visits for individuals experiencing homelessness and explore vulnerability factors. Methods. We used a unique highly detailed data set on sociodemographics of ED visits in San Diego, California, 2012 to 2019. We applied a time-stratified case-crossover design to study the association between various heat wave definitions and ED visits. We compared associations with a similar population not experiencing homelessness using coarsened exact matching. Results. Of the 24 688 individuals identified as experiencing homelessness who visited an ED, most were younger than 65 years (94%) and of non-Hispanic ethnicity (84%), and 14% indicated the need for a psychiatric consultation. Results indicated a positive association, with the strongest risk of ED visits during daytime (e.g., 99th percentile, 2 days) heat waves (odds ratio = 1.29; 95% confidence interval = 1.02, 1.64). Patients experiencing homelessness who were younger or elderly and who required a psychiatric consultation were particularly vulnerable to heat waves. Odds of ED visits were higher for individuals experiencing homelessness after matching to nonhomeless individuals based on age, gender, and race/ethnicity. Conclusions. It is important to prioritize individuals experiencing homelessness in heat action plans and consider vulnerability factors to reduce their burden. (Am J Public Health. 2022;112(1):98-106. https://doi.org/10.2105/AJPH.2021.306557).

Procalcitonin as a Predictive Tool for Death and ICU Admission among Febrile Neutropenic Patients Visiting the Emergency Department.

Background and Objectives: Risk stratification tools for febrile neutropenia exist but are infrequently utilized by emergency physicians. Procalcitonin may provide emergency physicians with a more objective tool to identify patients at risk of decompensation. Materials and Methods: We conducted a retrospective cohort study evaluating the use of procalcitonin in cases of febrile neutropenia among adult patients presenting to the Emergency Department compared to a non-neutropenic, febrile control group. Our primary outcome measure was in-hospital mortality with a secondary outcome of ICU admission. Results: Among febrile neutropenic patients, a positive initial procalcitonin value was associated with significantly increased odds of inpatient mortality after adjusting for age, sex, race, and ethnicity (AOR 9.912, p < 0.001), which was similar, though greater than, our non-neutropenic cohort (AOR 2.18, p < 0.001). All febrile neutropenic patients with a positive procalcitonin were admitted to the ICU. Procalcitonin had a higher sensitivity and negative predictive value (NPV) in regard to mortality and ICU admission for our neutropenic group versus our non-neutropenic control. Conclusions: Procalcitonin appears to be a valuable tool when attempting to risk stratify patients with febrile neutropenia presenting to the emergency department. Procalcitonin performed better in the prediction of death and ICU admission among patients with febrile neutropenia than a similar febrile, non-neutropenic control group.

Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position.

BACKGROUND: The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise. METHODS: Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences. RESULTS: We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001). CONCLUSIONS: In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.

Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits.

BACKGROUND: The traditional model of emergency care may not be sufficient to address the complex care needs of older adults, who present to the emergency department with multiple comorbidities, geriatric syndromes, and social determinants of health, complicating diagnosis and management. Geriatric emergency departments (GEDs) have emerged throughout the last decade to address these concerns and improve the emergency care of older adults. OBJECTIVE: Our aim was to describe the policies, procedures, and workflow of our GEDs, and to provide data on patient outcomes and discuss challenges and recommendations in the development and implementation of a GED. DISCUSSION: Our GED includes interdisciplinary staff trained in geriatric emergency medicine, evidence-based protocols for geriatric care, physical modifications to accommodate older adults' functional limitations, administration of geriatric assessments, care coordination with case managers and social workers, and referrals to care. Assessments screen for geriatric syndromes and social determinants of health. Quality improvement is a critical component and includes a robust medication safety plan to reduce use of potentially inappropriate medications. Hospital administrators considering developing a GED should create a care planning team, conduct an institutional needs assessment, and identify the GED model that will most efficiently help them achieve an age-friendly health system. CONCLUSIONS: The GED will play an important role in addressing the diverse health care needs of older adults in the coming decades. Future research studies of health outcomes among older adults receiving care at GEDs compared with traditional EDs will be critical in informing future improvements and innovations in geriatric emergency care.

Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department.

BACKGROUND: There is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults. METHODS: This was a retrospective cohort study within two geriatric emergency departments (GEDs) at a large academic health system. One hundred patients 65 years or older who visited a GED between March 10, 2020 and August 9, 2020 and tested positive for COVID-19 were examined. Electronic medical records were used to determine presenting COVID-19-related symptoms, comorbidities, and clinical outcomes. Descriptive statistics are reported with associated 95% confidence intervals (CIs). RESULTS: In the overall sample, mean age was 75.9 years; 18% were 85 years or older; 50% were male; and 46.0% were Hispanic. Relative to non-Hispanic patients with COVID-19, Hispanic patients with COVID-19 had a higher percentage of shortness of breath (78.3% vs. 51.9%; difference: 26.4%; 95% CI 7.6-42.5%), pneumonia (82.6% vs. 50.0%; difference: 32.6%; 95% CI 14.1-47.9%), acute respiratory distress syndrome (13.0% vs. 1.9%; difference: 11.1%; 95% CI 0.7-23.9%), and acute kidney failure (41.3% vs. 22.2%; difference: 19.1%; 95% CI 0.9-36.0%). Rates of other poor outcomes, including hospitalization, intensive care unit (ICU) admission, return visits to the GED within 30 days of discharge, or death, did not significantly differ between Hispanic and non-Hispanic patients with COVID-19. CONCLUSIONS: These preliminary data show that older Hispanic patients relative to non-Hispanic patients with COVID-19 presenting to a GED did not experience worse outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death.

Factors Associated With Geriatric Frequent Users of Emergency Departments.

STUDY OBJECTIVE: Frequent users of the emergency department (ED) are often associated with increased health care costs. Limited research is devoted to frequent ED use within the increasing senior population, which accounts for the highest use of health care resources. We evaluate patient characteristics and patterns of ED use among geriatric patients. METHODS: This was a multicenter, retrospective, longitudinal, cohort study of ED visits among geriatric patients older than 65 years in 2013 and 2014. Logistic regression analysis was used to identify independent associations with frequent users. The setting was a nonpublic statewide database in California, which includes 326 licensed nonfederal hospitals. We included all geriatric patients within the database who were older than 65 years and had an ED visit in 2014, for a total of 1,259,809 patients with 2,792,219 total ED visits. The main outcome was frequent users, defined as having greater than or equal to 6 ED visits in a 1-year period, starting from their last visit in 2014. RESULTS: Overall, 5.7% of geriatric patients (n=71,449) were identified as frequent users of the ED. They accounted for 21.2% (n=592,407) of all ED visits. The associations of frequent ED use with the largest magnitude were patients with an injury-related visit (odds ratio 3.8; 95% confidence interval 3.8 to 3.9), primary diagnosis of pain (odds ratio 5.5; 95% confidence interval 5.4 to 5.6), and comorbidity index score greater than or equal to 3 (odds ratio 7.2; 95% confidence interval 7.0 to 7.5). CONCLUSION: Geriatric frequent users are likely to have comorbid conditions and be treated for conditions related to pain and injuries. These findings provide evidence to guide future interventions to address these needs that could potentially decrease frequent ED use among geriatric patients.

A Description of a Health System's Emergency Department Patients Who Were Part of a Large Hepatitis A Outbreak.

BACKGROUND: A recent hepatitis A virus (HAV) outbreak in San Diego, California represents one of the largest HAV outbreaks in the United States. The County of San Diego Health and Human Services Agency identified homelessness and illicit or injection drug use as risk factors for contracting HAV during this outbreak. OBJECTIVE: We describe those patients who presented to our Emergency Department (ED) and were identified as HAV positive. METHODS: This was a retrospective descriptive study conducted at a tertiary care university health system's EDs from November 2016 to February 2018. Included were those of all ages who tested positive for HAV immunoglobulin M antibody. Outcome measures included: 1) demographic data; 2) number of patients testing positive for HAV by week and month of the outbreak; 3) homeless status, illicit and injection drug use, and alcohol use; 4) ED chief complaint; 5) initial liver function and coagulopathy test results, hepatitis B and C test results, and initial vital signs; 6) admission status; 7) death; and 8) the 7-day ED revisit rate for nonadmitted patients and the 30-day all-cause readmission rate for admitted patients. RESULTS: We identified 57,721 patients with at least one ED visit, and 1,453 of these were tested for HAV; 133 patients (9.2%) tested positive. Average age was 45.1 years, and 91 (68.4%) were male. Eighty-six patients (64.7%) were homeless and 53 patients (39.8%) reported illicit or injection drug use; 64 patients (48.1%) had chief complaints consistent with typical HAV symptoms. Most patients (112 or 84.2%) were admitted. Nine patients (6.8%) were admitted to a critical care setting; 8 patients (6%) died. CONCLUSIONS: During this large HAV outbreak, 9% of those screened for HAV tested positive. The majority were homeless, and 40% reported illicit or injection drug use. Most required hospitalization, and 6% of patients died.

A Multidisciplinary Bootcamp as an Educational Launch to a Geriatric Emergency Department.

BACKGROUND: Emergency department (ED) visits are increasing among patients ≥65 years of age. Geriatric EDs (GED) provide specialized emergency care for this older population. Interdisciplinary education of GED staff and providers is needed as part of the development of a GED. OBJECTIVES: We sought to describe the effective use of a GED bootcamp as an educational mechanism for the introduction of a GED to a health system. METHODS: An all-day, in-person GED bootcamp was held on the campus of our health system's medical school campus and was led by experts in geriatric emergency care. Participants in the bootcamp were professionals from a variety of health care fields and medical specialties as well as health care administrators and health policy professionals. Bootcamp attendees were administered a survey at the completion of the bootcamp. The survey asked about knowledge and interest in concepts relating to GEDs that the participants had both before and after attending the bootcamp. RESULTS: A total of 100 participants from a range of health care fields and medical specialties were present for the GED bootcamp. Fifty percent of bootcamp participants completed both before and after bootcamp survey questions. Among these, there was a significant increase in the level of high knowledge and interest in concepts relating to GEDs when comparing pre- and postbootcamp survey results (p < 0.001). CONCLUSIONS: An all-day, in-person GED bootcamp was an effective forum to bring together an interdisciplinary health care group and provide meaningful emergency geriatric care education.

Effect of a Computerized Alert on Emergency Department Hepatitis A Vaccination in Homeless Patients During a Large Regional Outbreak.

BACKGROUND: While the overall incidence of hepatitis A has declined markedly since the introduction of a vaccine, sporadic cases and outbreaks of the disease continue to occur. OBJECTIVE: Our aim was to evaluate the effectiveness of an electronic health record (EHR) provider alert as part of an outbreak-control vaccination program implemented in the emergency department (ED). METHODS: We conducted a retrospective study assessing the impact of a Best Practice Alert (BPA) built into an EHR to prompt providers when a patient was homeless to consider hepatitis A vaccination in the ED. Data were collected over three 6-month time periods: a historical control period, a pre-intervention period, and an intervention period. RESULTS: There were no vaccinations given in the ED in the historical period, which increased to 465 after the implementation of the BPA. During the implementation period, there were 1,482 visits identified among 1,131 patients that met the inclusion criteria. Of these, there were 1,147 (77.5%) visits where the patient either received the vaccine in the ED, had already received the vaccine, or it was not indicated due to the current medical issue. There were also 333 (22.5%) visits where the BPA was active for potential vaccination eligibility, but did not receive it in the ED. CONCLUSIONS: We leveraged an informatics tool developed within our EHR to identify high-risk patients and remind providers of the availability of vaccination in the ED. Using these tools enabled providers to increase vaccination efforts within our ED to help control the community-wide outbreak.

Care of the Critically Ill Pregnant Patient and Perimortem Cesarean Delivery in the Emergency Department.

BACKGROUND: Maternal resuscitation in the emergency department requires planning and special consideration of the physiologic changes of pregnancy. Perimortem cesarean delivery (PMCD) is a rare but potentially life-saving procedure for both mother and fetus. Emergency physicians should be aware of the procedure's indications and steps because it needs to be performed rapidly for the best possible outcomes. OBJECTIVE: We sought to review the approach to the critically ill pregnant patient in light of new expert guidelines, including indications for PMCD and procedural techniques. DISCUSSION: The prevalence of maternal cardiac arrest and survival outcomes of PMCD in the emergency department setting are difficult to estimate. Advanced cardiovascular life support protocols should be followed in maternal arrest with special considerations made based on the physiologic changes of pregnancy. The latest recommendations for maternal resuscitation are reviewed, including advance planning, rapid determination of gestational age, emergent delivery, and postprocedure considerations for PMCD. CONCLUSIONS: Maternal resuscitation requires knowledge of physiologic changes and evidence-based recommendations. PMCD outcomes are best for both mother and fetus when the procedure is performed rapidly and efficiently in the appropriate setting. Emergency physicians should be familiar with this unique clinical scenario so they are adequately prepared to intervene in order to improve maternal and fetal morbidity and mortality.

Survey and Chart Review to Estimate Medicare Cost Savings for Home Health as an Alternative to Hospital Admission Following Emergency Department Treatment.

BACKGROUND: Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED. OBJECTIVE: We sought to estimate Medicare cost savings resulting from using the Home Health benefit to provide treatment, when appropriate, as an alternative to inpatient admission from the ED. METHODS: This is a prospective study of patients admitted from the ED. A survey tool was used to query both emergency physicians (EPs) and patient medical record data to identify potential candidates and treatments for home-based care alternatives. Patient preferences were also surveyed. Cost savings were estimated by developing a model of Medicare Home Health to serve as a counterpart to the actual hospital-based care. RESULTS: EPs identified 40% of the admitted patients included in the study as candidates for home-based care. The top three major diagnostic categories included diseases and disorders of the respiratory system, digestive system, and skin. Services included intravenous hydration, intravenous antibiotics, and laboratory testing. The average estimated cost savings between the Medicare inpatient reimbursement and the Home Health counterpart was approximately $4000. Of the candidate patients surveyed, 79% indicated a preference for home-based care after treatment in the ED. CONCLUSIONS: Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED.

Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome.

BACKGROUND: Orbital compartment syndrome is a sight-threatening emergency. Vision may be preserved when timely intervention is performed. OBJECTIVE: To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration. DISCUSSION: Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome. CONCLUSIONS: Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss.

Identifying frequent users of emergency department resources.

BACKGROUND: There is growing focus on frequent users of acute care resources. If these patients can be identified, interventions can be established to offer more consistent management plans to decrease inappropriate utilization. OBJECTIVE: To compare a hospital-specific approach with a region-wide approach to identify frequent Emergency Department (ED) users. METHODS: A retrospective multi-center cohort study of hospital ED visits from all 18 nonmilitary, acute care hospitals serving the San Diego region (population 3.2 million) between 2008 and 2010 using data submitted to the California Office of Statewide Health Planning and Development. Frequent users and super users were defined as having 6 to 20 and 21 or more visits, respectively, during any consecutive 12 months in the study period. Comparisons between community-wide and hospital-specific methods were made. RESULTS: There were 925,719 individual patients seen in an ED, resulting in 2,016,537 total visits. There were 28,569 patients identified as frequent users and 1661 identified as super users, using a community-wide approach. Individual hospitals could identify 15.6% to 62.4% of all frequent users, and from 0.3% to 15.2% of all the super users who visited their facility. Overall, the hospital-specific approach identified 20,314 frequent users and 571 super users, failing to identify 28.9% of frequent users and 65.6% of super users visiting San Diego County EDs that would otherwise have been identified using a community-wide approach. CONCLUSIONS: A community-wide identification method resulted in greater numbers of individuals being identified as frequent and super ED users than when utilizing individual hospital data.

Emergency department management of shoulder dystocia.

BACKGROUND: Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome. OBJECTIVE: To review multiple techniques for managing a shoulder dystocia in the ED. DISCUSSION: We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort. CONCLUSIONS: Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.

Impact of skilled nursing facility (SNF) 3-day hospitalization requirement waiver during the COVID-19 pandemic on emergency department and inpatient SNF discharges in California.

Objective: We sought to study the impact of the Centers for Medicare & Medicaid services (CMS) waiver of the 3-day hospitalization requirement for skilled nursing facility (SNF) care implemented as part of the Federal COVID-19 response on emergency department (ED) and inpatient hospital SNF discharges. Methods: We conducted a multicenter retrospective cohort study of hospital ED and inpatient visits in California during 18 months before (prewaiver, September 2018-February 2020) and 18 months after (waiver, March 2020-August 2021) waiver implementation. Data were collected from all adult ED and admitted patients utilizing California Department of Health Care Access and Information datasets from all acute care hospitals licensed in the state. Prewaiver and waiver periods were compared for SNF discharge/disposition rates stratified by patient demographic and hospital data with differences in the proportion and 95% confidence interval [CI] reported (SPSS). Results: SNF discharges decreased from the prewaiver to waiver periods from the ED (-7.4% [CI -8.1%, -6.6%]), along with larger declines occurring from the inpatient hospital setting (-18.1% [CI -18.4%, -17.9%]). For Medicare beneficiaries, there was a smaller decrease in ED SNF rates (-3.8% [CI -4.7%, -2.9%]), and there was no significant change for SNF discharge rates for inpatient admissions with a length of stay (LOS) <3 days (+1.0% [CI 0.0%, 2.1%]). Conclusion: In California, the CMS waiver did not result in an increase, but an actual decrease rate of SNF discharges from the ED and inpatient setting, though with smaller declines for the ED, Medicare patients, and those with a LOS <3 days.

Impact of a deep learning sepsis prediction model on quality of care and survival.

Sepsis remains a major cause of mortality and morbidity worldwide. Algorithms that assist with the early recognition of sepsis may improve outcomes, but relatively few studies have examined their impact on real-world patient outcomes. Our objective was to assess the impact of a deep-learning model (COMPOSER) for the early prediction of sepsis on patient outcomes. We completed a before-and-after quasi-experimental study at two distinct Emergency Departments (EDs) within the UC San Diego Health System. We included 6217 adult septic patients from 1/1/2021 through 4/30/2023. The exposure tested was a nurse-facing Best Practice Advisory (BPA) triggered by COMPOSER. In-hospital mortality, sepsis bundle compliance, 72-h change in sequential organ failure assessment (SOFA) score following sepsis onset, ICU-free days, and the number of ICU encounters were evaluated in the pre-intervention period (705 days) and the post-intervention period (145 days). The causal impact analysis was performed using a Bayesian structural time-series approach with confounder adjustments to assess the significance of the exposure at the 95% confidence level. The deployment of COMPOSER was significantly associated with a 1.9% absolute reduction (17% relative decrease) in in-hospital sepsis mortality (95% CI, 0.3%-3.5%), a 5.0% absolute increase (10% relative increase) in sepsis bundle compliance (95% CI, 2.4%-8.0%), and a 4% (95% CI, 1.1%-7.1%) reduction in 72-h SOFA change after sepsis onset in causal inference analysis. This study suggests that the deployment of COMPOSER for early prediction of sepsis was associated with a significant reduction in mortality and a significant increase in sepsis bundle compliance.

Alternative treatments of pneumothorax.

BACKGROUND: Pneumothorax has traditionally been treated in the Emergency Department by tube thoracostomy. However, this is an invasive procedure with high risk of complication and prolonged hospitalization. DISCUSSION: In select settings, there are alternative forms of management of pneumothorax that carry lower risks and may reduce hospital stay. This article reviews the settings in which less invasive treatment, including observation alone, may be indicated. This article also reviews the techniques for simple aspiration and small-bore catheter insertion (by either Seldinger or catheter-over-wire technique) with Heimlich valve, as well as the indications, contraindications, and potential risks and benefits of each. CONCLUSIONS: The practices of observation, simple aspiration, and small-bore catheter insertion with Heimlich valve for selected patients may decrease complications, time, and costs by avoiding invasive procedures and hospital admissions.

Clinical and financial outcome impacts of comprehensive geriatric assessment in a level 1 geriatric emergency department.

BACKGROUND: The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED. METHODS: This is a retrospective matched case-control study at a level 1 geriatric ED (GED) from January 1, 2018-March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective. RESULTS: GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] -17.0%, -9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90-days post discharge (-11.3%, 95% CI -15.6%, -7.1%, p-value < 0.001; and -10.0, 95% CI -13.8%, -6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit. CONCLUSIONS: GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings.

Ransomware Attack Associated With Disruptions at Adjacent Emergency Departments in the US.

Importance: Cyberattacks on health care delivery organizations are increasing in frequency and sophistication. Ransomware infections have been associated with significant operational disruption, but data describing regional associations of these cyberattacks with neighboring hospitals have not been previously reported, to our knowledge. Objective: To examine an institution's emergency department (ED) patient volume and stroke care metrics during a month-long ransomware attack on a geographically proximal but separate health care delivery organization. Design, Setting, and Participants: This before and after cohort study compares adult and pediatric patient volume and stroke care metrics of 2 US urban academic EDs in the 4 weeks prior to the ransomware attack on May 1, 2021 (April 3-30, 2021), as well as during the attack and recovery (May 1-28, 2021) and 4 weeks after the attack and recovery (May 29 to June 25, 2021). The 2 EDs had a combined mean annual census of more than 70 000 care encounters and 11% of San Diego County's total acute inpatient discharges. The health care delivery organization targeted by the ransomware constitutes approximately 25% of the regional inpatient discharges. Exposure: A month-long ransomware cyberattack on 4 adjacent hospitals. Main Outcomes and Measures: Emergency department encounter volumes (census), temporal throughput, regional diversion of emergency medical services (EMS), and stroke care metrics. Results: This study evaluated 19 857 ED visits at the unaffected ED: 6114 (mean [SD] age, 49.6 [19.3] years; 2931 [47.9%] female patients; 1663 [27.2%] Hispanic, 677 [11.1%] non-Hispanic Black, and 2678 [43.8%] non-Hispanic White patients) in the preattack phase, 7039 (mean [SD] age, 49.8 [19.5] years; 3377 [48.0%] female patients; 1840 [26.1%] Hispanic, 778 [11.1%] non-Hispanic Black, and 3168 [45.0%] non-Hispanic White patients) in the attack and recovery phase, and 6704 (mean [SD] age, 48.8 [19.6] years; 3326 [49.5%] female patients; 1753 [26.1%] Hispanic, 725 [10.8%] non-Hispanic Black, and 3012 [44.9%] non-Hispanic White patients) in the postattack phase. Compared with the preattack phase, during the attack phase, there were significant associated increases in the daily mean (SD) ED census (218.4 [18.9] vs 251.4 [35.2]; P < .001), EMS arrivals (1741 [28.8] vs 2354 [33.7]; P < .001), admissions (1614 [26.4] vs 1722 [24.5]; P = .01), patients leaving without being seen (158 [2.6] vs 360 [5.1]; P < .001), and patients leaving against medical advice (107 [1.8] vs 161 [2.3]; P = .03). There were also significant associated increases during the attack phase compared with the preattack phase in median waiting room times (21 minutes [IQR, 7-62 minutes] vs 31 minutes [IQR, 9-89 minutes]; P < .001) and total ED length of stay for admitted patients (614 minutes [IQR, 424-1093 minutes] vs 822 minutes [IQR, 497-1524 minutes]; P < .001). There was also a significant increase in stroke code activations during the attack phase compared with the preattack phase (59 vs 102; P = .01) as well as confirmed strokes (22 vs 47; P = .02). Conclusions and Relevance: This study found that hospitals adjacent to health care delivery organizations affected by ransomware attacks may see increases in patient census and may experience resource constraints affecting time-sensitive care for conditions such as acute stroke. These findings suggest that targeted hospital cyberattacks may be associated with disruptions of health care delivery at nontargeted hospitals within a community and should be considered a regional disaster.