Demographic and clinical correlates of acute and convalescent SARS-CoV-2 infection among patients of a U.S. emergency department.

BACKGROUND: Emergency Departments (EDs) have served as critical surveillance sites for infectious diseases. We sought to determine the prevalence and temporal trends of acute (by PCR) and convalescent (by antibody [Ab]) SARS-CoV-2 infection during the earliest phase of the pandemic among patients in an urban ED in Baltimore City. METHODS: We tested remnant blood samples from 3255 unique ED patients, collected between March 16th and May 31st 2020 for SARS-CoV-2 Ab. PCR for acute SARS-CoV-2 infection from nasopharyngeal swabs was obtained on any patients based on clinical suspicion. Hospital records were abstracted and factors associated with SARS-CoV-2 infection were assessed. RESULTS: Of 3255 ED patients, 8.2% (95%CI: 7.3%, 9.2%) individuals had evidence of SARS-CoV-2 infection; 155 PCR+, 78 Ab+, and 35 who were both PCR+ and Ab+. Prevalence of disease increased throughout the study period, ranging from 3.2% (95%CI: 1.8%, 5.2%) PCR+ and 0.6% (95%CI: 0.1%, 1.8%) Ab+ in March, to 6.2% (95%CI: 5.1%, 7.4%) PCR+ and 4.2% (95%CI: 3.3%, 5.3%) Ab+ in May. The highest SARS-CoV-2 prevalence was found in Hispanic individuals who made up 8.4% (95%CI: 7.4%, 9.4%) of individuals screened, but 35% (95%CI: 29%, 41%) of infections (PCR and/or Ab+). Demographic and clinical factors independently associated with acute infection included Hispanic ethnicity, loss of smell or taste, subjective fever, cough, muscle ache and fever. Factors independently associated with convalescent infection were Hispanic ethnicity and low oxygen saturation. CONCLUSIONS: The burden of COVID-19 in Baltimore City increased dramatically over the 11-week study period and was disproportionately higher among Hispanic individuals. ED-based surveillance methods are important for identifying both acute and convalescent SARS-CoV-2 infections and provides important information regarding demographic and clinical correlates of disease in the local community.

Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial.

Importance: Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis. Objective: To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis. Design, Setting, and Participants: Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. Interventions: Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. Main Outcomes and Measures: The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. Results: Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group. Conclusions and Relevance: Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference. Trial Registration: ClinicalTrials.gov Identifier: NCT03509350.

Nurse practitioners and physician assistants in emergency medical services who billed independently, 2012-2016.

OBJECTIVE: As nurse practitioners (NPs) and physician assistants (PAs) become an integral part of delivering emergency medical services, we examined the involvement of NPs and PAs who billed independently in emergency departments (EDs). METHODS: We used Medicare provider utilization and payment data from 2012 to 2016 to conduct a retrospective analysis. We examined the changes in the number of each clinician type who billed independently for four common emergency services (CPT codes: 99282-5), the change in their service volume, and the change in their average number of services billed. RESULTS: Between 2012 and 2016, the proportion of NPs and PAs billing independently increased from 18% to 22% for ED visits of low severity (99282), 23% to 29% for visits with moderate severity (99283), 21% to 27% for visits with high severity (99284), 18% to 24% for visit with the highest severity (99285), and 23% to 29% across all four services. The proportion of services provided by emergency physicians decreased from 66% to 63% across all four services, and from 11% to 9% for internists and family physicians. The number of NPs, PAs billing independently, and emergency physicians increased by 65%, 35% and 12% respectively. CONCLUSIONS: NPs and PAs are increasingly billing emergency services of all levels of severity, independent of physicians. This trend is driven by a growing number of NPs and PAs independently billing services, despite a relatively stable number of emergency physicians (excepting the decline in rural areas), and diminished involvement of family physicians and internists in EDs.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments.

STUDY OBJECTIVES: The shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in specific disease states. However, there is scarcity of data about the utility of the SI in the general emergency department (ED)population. Our goal was to use a large national database of EDs in the United States (US) to determine whether the likelihood of inpatient mortality and hospital admission was associated with initial SI at presentation. METHODS: Data from the National Hospital Ambulatory Medical Care Survey were retrospectively reviewed to obtain a weighted sample of all US ED visits between 2005 and 2010. All adults >18 years old who survived the ED visit were included, regardless of their chief complaint. Likelihood ratios (LR) were calculated for a range of SI values, in order to determine SI thresholds most predictive of hospital admission and inpatient mortality. +LRs >5 were considered to be clinically significant. RESULTS: A total of 526 455 251 adult patient encounters were included in the analysis. 56.9% were women, 73.9% were white and 53.2% were between the ages of 18 and 44 years. 88 326 638 (15.7%) unique ED visits resulted in hospital admission and 1 927 235 (2.6%) visits resulted in inpatient mortality. SI>1.3 was associated with a clinically significant increase in both the likelihood of hospital admission (+LR=6.64) and inpatient mortality (+LR=5.67). SI>0.7 and >0.9, the traditional cited cut-offs, were only associated with marginal increases (+LR= 1.13; 1.54 for SI>0.7 and +LR=1.95; 2.59 for SI>0.9 for hospital admission and inpatient mortality, respectively). CONCLUSIONS: In this largest retrospective study to date on SI in the general ED population, we demonstrated that initial SI at presentation to the ED could potentially be useful in predicting the likelihood of hospital admission and inpatient mortality, which could help guide rapid and accurate acuity designation, resource allocation and disposition.

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments.

STUDY OBJECTIVE: A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland. METHODS: We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015). RESULTS: The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. CONCLUSION: There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland.

Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality.

STUDY OBJECTIVES: The shock index (SI), defined as the ratio of HR to systolic BP, has been studied as an alternative prognostic tool to traditional vital signs in specific disease states and subgroups of patients. However, literature regarding its utility in the general ED population is lacking. Our main objective was to determine the probability of admission and inpatient mortality based on the first measured SI at initial presentation in the general adult ED population in our tertiary care centre. METHODS: A retrospective chart review of all adult patients (≥18 years old) presenting to the ED at our tertiary care centre over a 12-month period was conducted. Likelihood ratios (LRs) were calculated in order to determine the optimal SI cut-off for predicting hospital admission and inpatient mortality. RESULTS: We reviewed 58 336 ED patient encounters occurring between 1 October 2012 and 30 September 2013. SI >1.2 was associated with a large increase in the likelihood of hospital admission, with a positive LR (+LR) of 11.69 (95% CI 9.50 to 14.39) and a moderate increase in the likelihood of inpatient mortality with a +LR of 5.82 (95% CI 4.31 to 7.85). SI >0.7 and >0.9, the traditional 'normal' cut-offs cited in the literature, were only associated with minimal to small increases in the likelihood of admission and inpatient mortality. CONCLUSIONS: In our single-centre study, the initial SI recorded in the ED shows promise as a clinical metric in the general adult ED population, increasing the probability of both hospital admission and inpatient mortality, specifically at a threshold of SI >1.2.

Evaluation of the Centers for Disease Control and Prevention Recommendations for Hepatitis C Virus Testing in an Urban Emergency Department.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommends 1-time hepatitis C virus (HCV) testing in the 1945-1965 birth cohort, in addition to targeted risk-based testing. Emergency departments (EDs) are key venues for HCV testing because of the population served and success in HIV screening. We determined the burden of undocumented HCV infection in our ED, providing guidance for implementation of ED-based HCV testing. METHODS: An 8-week seroprevalence study was conducted in an urban ED in 2013. All patients with excess blood collected for clinical purposes were included. Demographic and clinical information including documented HCV infection was obtained from electronic medical records. HCV antibody testing was performed on excess samples. RESULTS: Of 4713 patients, 652 (13.8%) were HCV antibody positive. Of these, 204 (31.3%) had undocumented HCV infection. Among patients with undocumented infections, 99 (48.5%) would have been diagnosed based on birth cohort testing, and an additional 54 (26.5%) would be identified by risk-based testing. If our ED adhered to the CDC guidelines, 51 (25.0%) patients with undocumented HCV would not have been tested. Given an estimated 7727 unique ED patients with HCV infection in a 1-year period, birth cohort plus risk-based testing would identify 1815 undocumented infections, and universal testing would identify additional 526 HCV-infected persons. CONCLUSIONS: Birth cohort-based testing would augment identification of undocumented HCV infections in this ED 2-fold, relative to risk-based testing only. However, our data demonstrate that one-quarter of infections would remain undiagnosed if current CDC birth cohort recommendations were employed, suggesting that in high-risk urban ED settings a practice of universal 1-time testing might be more effective.

Evaluation of hidden HIV infections in an urban ED with a rapid HIV screening program.

BACKGROUND: To investigate the prevalence of undiagnosed HIV infections in an emergency department (ED) with an established screening program. METHODS: Evaluation of the prevalence and risk factors for HIV from an 8-week (June 24, 2007-August 18, 2007) identity-unlinked HIV serosurvey, conducted at the same time as an ongoing opt-in rapid oral-fluid HIV screening program. Testing facilitators offering 24/7 bedside rapid testing to patients aged 18 to 64 years, with concordant collection of excess sera collected as part of routine clinical procedures. Known HIV positivity was determined by (1) medical record review or self-report from the screening program and/or (2) presence of antiretrovirals in serum specimens. RESULTS: Among 3207 patients, 1165 (36.3%) patients were offered an HIV test. Among those offered, 567 (48.7%) consented to testing. Concordance identity-unlinked study revealed that the prevalence of undiagnosed infections was as follows: 2.3% in all patients, 1.0% in those offered testing vs 3.0% in those not offered testing (P < .001); and 1.3% in those who declined testing compared with 0.4% in those who were tested (P = .077). Higher median viral loads were observed in those not offered testing (14255 copies/mL; interquartile range, 1147-64354) vs those offered testing (1865 copies/mL; interquartile range, undetectable-21786), but the difference was not statistically significant. CONCLUSIONS: High undiagnosed HIV prevalence was observed in ED patients who were not offered HIV testing and those who declined testing, compared with those who were tested. This indicates that even with an intensive facilitator-based rapid HIV screening model, significant missed opportunities remain with regard to identifying undiagnosed infections in the ED.

Emergency Department Evaluation of Traumatic Brain Injury in the United States, 2009-2010.

OBJECTIVE: To determine the dimensions of traumatic brain injury (TBI) evaluation in US emergency department (EDs) to inform potential application of novel diagnostic tests. SETTING: US EDs. PARTICIPANTS: National Hospital Ambulatory Medical Care Survey of ED visits in 2009 and 2010 where TBI was evaluated (1) and diagnosed either clinically or (2) with head computed tomographic (CT) scans. DESIGN: Retrospective cross-sectional. RESULTS: TBI was evaluated during 4.8 (95% confidence interval [CI], 4.2-5.4) million visits per year; and head CT scan was performed in 82% of TBI evaluations (3.9 [95% CI, 3.4-4.4] million visits per year). TBI was diagnosed in 52% of evaluations (2.5 [95% CI, 2.1-2.8] million visits per year). Among those who received head CT scans, 9% had CT evidence of traumatic abnormalities. Among patients evaluated for TBI who had a Glasgow Coma Scale score recorded, 94.5% were classified as having mild TBI, 2.1% as moderate TBI, and 3.5% as severe TBI. Among patients with International Classification of Diseases, Ninth Revision, Clinical Modification, codes permitting the calculation of head Abbreviated Injury Scale scores 9.0%, 85.0%, 2.5%, 3.2%, 0.3%, and 0% had head Abbreviated Injury Scale scores of 1, 2, 3, 4, 5, and 6, respectively. Of patients evaluated for TBI, 31% had other head/face/neck injuries, 10% had spine and back injuries, 7% had torso injuries, and 14% had extremity injuries. CONCLUSION: The ED is the main gateway to medical care for millions of patients evaluated for TBI each year. Novel diagnostic tests are needed to improve ED diagnosis and management of TBI.

HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department.

STUDY OBJECTIVE: The recently released HIV Care Continuum Initiative is a cornerstone of the National AIDS Strategy and a model for improving care for those living with HIV. To our knowledge, there are no studies exploring the entirety of the HIV Care Continuum for patients in the emergency department (ED). We determine gaps in the HIV Care Continuum to identify potential opportunities for improved care for HIV-infected ED patients. METHODS: A mixed-methods approach was used in 1 inner-city ED in 2007. Data elements were derived from an identity-unlinked HIV seroprevalence study, an ongoing nontargeted HIV screening program, and a structured survey of known HIV-positive ED patients. RESULTS: Identity-unlinked testing of 3,417 unique ED patients found that 265 (7.8%) were HIV positive. Of patients testing HIV positive, 73% had received a previous diagnosis (based on self-report, chart review, or presence of antiretrovirals in serum), but only 61% were recognized by the clinician as being HIV infected (based on self-report or chart review). Of patients testing positive, 43% were linked to care, 39% were retained in care, 27% were receiving antiretrovirals, 26% were aware of their receiving antiretroviral treatment, 22% were virally suppressed, and only 9% were self-aware of their viral suppression. CONCLUSION: To our knowledge, this study is the first to quantify gaps in HIV care for an ED patient population, with the HIV Care Continuum as a framework. Our findings identified distinct phases (ie, testing, provider awareness of HIV diagnosis, and linkage to care) in which the greatest opportunities for intervention exist, if appropriate resources were allocated. This schema could serve as a model for other indolent treatable diseases frequently observed in EDs, where continuity of care is critical.

Disaster Metrics: Evaluation of de Boer's Disaster Severity Scale (DSS) Applied to Earthquakes.

INTRODUCTION: Quantitative measurement of the medical severity following multiple-casualty events (MCEs) is an important goal in disaster medicine. In 1990, de Boer proposed a 13-point, 7-parameter scale called the Disaster Severity Scale (DSS). Parameters include cause, duration, radius, number of casualties, nature of injuries, rescue time, and effect on surrounding community. Hypothesis This study aimed to examine the reliability and dimensionality (number of salient themes) of de Boer's DSS scale through its application to 144 discrete earthquake events. METHODS: A search for earthquake events was conducted via National Oceanic and Atmospheric Administration (NOAA) and US Geological Survey (USGS) databases. Two experts in the field of disaster medicine independently reviewed and assigned scores for parameters that had no data readily available (nature of injuries, rescue time, and effect on surrounding community), and differences were reconciled via consensus. Principle Component Analysis was performed using SPSS Statistics for Windows Version 22.0 (IBM Corp; Armonk, New York USA) to evaluate the reliability and dimensionality of the DSS. RESULTS: A total of 144 individual earthquakes from 2003 through 2013 were identified and scored. Of 13 points possible, the mean score was 6.04, the mode = 5, minimum = 4, maximum = 11, and standard deviation = 2.23. Three parameters in the DSS had zero variance (ie, the parameter received the same score in all 144 earthquakes). Because of the zero contribution to variance, these three parameters (cause, duration, and radius) were removed to run the statistical analysis. Cronbach's alpha score, a coefficient of internal consistency, for the remaining four parameters was found to be robust at 0.89. Principle Component Analysis showed uni-dimensional characteristics with only one component having an eigenvalue greater than one at 3.17. The 4-parameter DSS, however, suffered from restriction of scoring range on both parameter and scale levels. CONCLUSION: Jan de Boer's DSS in its 7-parameter format fails to hold statistically in a dataset of 144 earthquakes subjected to analysis. A modified 4-parameter scale was found to quantitatively assess medical severity more directly, but remains flawed due to range restriction on both individual parameter and scale levels. Further research is needed in the field of disaster metrics to develop a scale that is reliable in its complete set of parameters, capable of better fine discrimination, and uni-dimensional in measurement of the medical severity of MCEs.

Does providing prescription information or services improve medication adherence among patients discharged from the emergency department? A randomized controlled trial.

STUDY OBJECTIVE: We determine whether prescription information or services improve the medication adherence of emergency department (ED) patients. METHODS: Adult patients treated at one of 3 EDs between November 2010 and September 2011 and prescribed an antibiotic, central nervous system, gastrointestinal, cardiac, or respiratory drug at discharge were eligible. Subjects were randomly assigned to usual care or one of 3 prescription information or services intervention groups: (1) practical services to reduce barriers to prescription filling (practical prescription information or services); (2) consumer drug information from MedlinePlus (MedlinePlus prescription information or services); or (3) both services and information (combination prescription information or services). Self-reported medication adherence, measured by primary adherence (prescription filling) and persistence (receiving medicine as prescribed) rates, was determined during a telephone interview 1 week postdischarge. RESULTS: Of the 3,940 subjects enrolled and randomly allocated to treatment, 86% (N=3,386) completed the follow-up interview. Overall, primary adherence was 88% and persistence was 48%. Across the sites, primary adherence and persistence did not differ significantly between usual care and the prescription information or services groups. However, at site C, subjects who received the practical prescription information or services (odds ratio [OR]=2.4; 95% confidence interval [CI] 1.4 to 4.3) or combination prescription information or services (OR=1.8; 95% CI 1.1 to 3.1) were more likely to fill their prescription compared with usual care. Among subjects prescribed a drug that treats an underlying condition, subjects who received the practical prescription information or services were more likely to fill their prescription (OR=1.8; 95% CI 1.0 to 3.1) compared with subjects who received usual care. CONCLUSION: Prescription filling and receiving medications as prescribed was not meaningfully improved by offering patients patient-centered prescription information and services.

Hospital-based shootings in the United States: 2000 to 2011.

STUDY OBJECTIVE: Workplace violence in health care settings is a frequent occurrence. Emergency departments (EDs) are considered particularly vulnerable. Gunfire in hospitals is of particular concern; however, information about such workplace violence is limited. Therefore, we characterize US hospital-based shootings from 2000 to 2011. METHODS: Using LexisNexis, Google, Netscape, PubMed, and ScienceDirect, we searched reports for acute care hospital shooting events in the United States for 2000 through 2011. All hospital-based shootings with at least 1 injured victim were analyzed. RESULTS: Of 9,360 search "hits," 154 hospital-related shootings were identified, 91 (59%) inside the hospital and 63 (41%) outside on hospital grounds. Shootings occurred in 40 states, with 235 injured or dead victims. Perpetrators were overwhelmingly men (91%) but represented all adult age groups. The ED environs were the most common site (29%), followed by the parking lot (23%) and patient rooms (19%). Most events involved a determined shooter with a strong motive as defined by grudge (27%), suicide (21%), "euthanizing" an ill relative (14%), and prisoner escape (11%). Ambient society violence (9%) and mentally unstable patients (4%) were comparatively infrequent. The most common victim was the perpetrator (45%). Hospital employees composed 20% of victims; physician (3%) and nurse (5%) victims were relatively infrequent. Event characteristics that distinguished the ED from other sites included younger perpetrator, more likely in custody, and unlikely to have a personal relationship with the victim (ill relative, grudge, coworker). In 23% of shootings within the ED, the weapon was a security officer's gun taken by the perpetrator. Case fatality inside the hospital was much lower in the ED setting (19%) than other sites (73%). CONCLUSION: Although it is likely that not every hospital-based shooting was identified, such events are relatively rare compared with other forms of workplace violence. The unpredictable nature of this type of event represents a significant challenge to hospital security and effective deterrence practices because most perpetrators proved determined and a significant number of shootings occur outside the hospital building.

Is inadequate human immunodeficiency virus care associated with increased ED and hospital utilization? A prospective study in human immunodeficiency virus-positive ED patients.

BACKGROUND: There is a lack of data on the effect(s) of suboptimal human immunodeficiency virus (HIV) care on subsequent health care utilization among emergency department (ED) patients with HIV. Findings on their ED and inpatient care utilization patterns will provide information on service provision for those who have suboptimal access to HIV-related care. METHODS: A pilot prospective study was conducted on HIV-positive patients in an ED. At enrollment, participants were interviewed regarding health care utilization. Participants were followed up for 1 year, during which time data on ED visits and hospitalizations were obtained from their patient records. Inadequate HIV care (IHC) was defined according to Infectious Diseases Society of America recommendations as less than 3 scheduled clinic visits for HIV care in the year before enrollment. Cox regression models were used to evaluate whether IHC was associated with increased hazard of health care utilization. RESULTS: Of 107 subjects, 36% were found to have IHC. Inadequate HIV care did not predict more frequent ED visits but was significantly associated with fewer hospitalizations (adjusted incidence rate ratio, 0.61 [95% CI: 0.43-0.86]). Inadequate HIV care did not significantly increase the hazard for earlier ED visit or hospitalization. However, further stratification analysis found that IHC increased the hazard of hospitalization for subjects without comorbid diseases (adjusted hazard ratio, 2.50 [95% CI: 1.10-5.68]). CONCLUSIONS: In our setting, IHC does not appear to be associated with earlier or more frequent ED visits but may lead to earlier hospitalization, particularly among those without other chronic diseases.

A Tale of 3 Pandemics: Severe Acute Respiratory Syndrome Coronavirus 2, Hepatitis C Virus, and Human Immunodeficiency Virus in an Urban Emergency Department in Baltimore, Maryland.

Background: We sought to determine the prevalence and sociodemographic and clinical correlates of acute and convalescent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections among emergency department (ED) patients in Baltimore. Methods: Remnant blood samples from 7450 unique patients were collected over 4 months in 2020 for SARS-CoV-2 antibody (Ab), HCV Ab, and HIV-1/2 antigen and Ab. Among them, 5012 patients were tested by polymerase chain reaction for SARS-CoV-2 based on clinical suspicion. Sociodemographics, ED clinical presentations, and outcomes associated with coinfections were assessed. Results: Overall, 729 (9.8%) patients had SARS-CoV-2 (acute or convalescent), 934 (12.5%) HCV, 372 (5.0%) HIV infection, and 211 patients (2.8%) had evidence of any coinfection (HCV/HIV, 1.5%; SARS-CoV-2/HCV, 0.7%; SARS-CoV-2/HIV, 0.3%; SARS-CoV-2/HCV/HIV, 0.3%). The prevalence of SARS-CoV-2 (acute or convalescent) was significantly higher in those with HCV or HIV vs those without (13.6% vs 9.1%, P < .001). Key sociodemographic disparities (race, ethnicity, and poverty) and specific ED clinical characteristics were significantly correlated with having any coinfections vs no infection or individual monoinfection. Among those with HCV or HIV, aged 18-34 years, Black race, Hispanic ethnicity, and a cardiovascular-related chief complaint had a significantly higher odds of having SARS-CoV-2 (prevalence ratios: 2.02, 2.37, 5.81, and 2.07, respectively). Conclusions: The burden of SARS-CoV-2, HCV, and HIV co-pandemics and their associations with specific sociodemographic disparities, clinical presentations, and outcomes suggest that urban EDs should consider implementing integrated screening and linkage-to-care programs for these 3 infections.

A comprehensive approach to achieving near 100% compliance with the Joint Commission Core Measures for pneumonia antibiotic timing.

BACKGROUND: Adherence to The Joint Commission (TJC) Core Measures benchmarks is required for hospital accreditation, and data are publicly reported as an indication of hospital quality. Published approaches to date for adhering to the pneumonia antibiotic timing (PN5c) Core Measure have shown moderate to limited success in reaching high levels of compliance. OBJECTIVE: The objective of the study was to evaluate the effectiveness of a 3-phased intervention directed at improving compliance with TJC pneumonia antibiotic administration within the 6-hour requirement (PN5c) in an academic urban emergency department. METHODS: A 3-phase interventional study with retrospective analysis of contemporaneous data collection during a 57-month period ending September 2009 was performed. Phase 0 was baseline, phase 1 was physician evaluation at triage, phase 2 was implementation of a specific pneumonia screening tool and pathway, and phase 3 was implementation of an emergency department electronic medical record system that facilitates removing subjects with "diagnostic uncertainty" from consideration. Main outcome measure was the proportion of patients receiving antibiotics within 6 hours among those meeting PN5c criteria. Mean times to antibiotics and percentage of compliance with PN5c were compared for each phase. RESULTS: Percentage of compliance with PN5c increased from a baseline of 77% through each of the 3 phases: 85%, 91%, and 95%, respectively (Cochran-Armitage trend, P < .001). Mean time to antibiotic administration decreased from a baseline of 285 minutes with each successive intervention to 224, 189, and 169 minutes, respectively (linear regression, P < .001). CONCLUSION: Implementation of a structured intervention that includes early physician triage, a screening tool for immediate imaging and reporting, and electronic record-facilitated compliance review effectively improves TJC PN5c compliance to high levels.

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

BACKGROUND: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. STUDY OBJECTIVE: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. METHODS: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. RESULTS: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. CONCLUSION: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.

Emergency Medicine Career Outcomes and Scholarly Pursuits: The Impact of Transitioning From a Three-year to a Four-year Niche-based Residency Curriculum.

OBJECTIVES: In 2008, our emergency medicine (EM) residency program transitioned from a 3-year to a 4-year format. We analyzed the effect that this change had on the scholarly productivity and career choice of graduates, hypothesizing that it would lead residents to be more scholarly productive and graduates to more frequently obtain academic appointments and leadership roles in their first postresidency positions. METHODS: This was a retrospective analysis of graduates (N = 95) from a single residency program that underwent a curriculum change from a 3-year to a 4-year format. Three cohorts prior to (n = 36) and five cohorts after (n = 59) this transition were included. The primary outcome of interest was the setting of graduates' first postresidency position. Secondary outcomes included completion of scholarly activity during training and attaining a leadership role in the first postresidency position. RESULTS: Of the 4-year program graduates, 44% obtained an academic position compared to 28% of 3-year program graduates. After confounders were controlled for, this difference was statistically discernible only if fellowships were excluded (including fellowship, odds ratio [OR] = 2.25, 95% CI = 0.87 to 5.78; excluding fellowship, OR = 3.53, 95% CI = 1.13 to 11.05). Four-year graduates were more likely to obtain a leadership position immediately after graduation (OR = 13.72, 95% CI = 2.45 to 76.99). Compared to residents in the 3-year program, residents in the 4-year format had a similar likelihood of producing any scholarly work by graduation (OR = 1.69, 95% CI = 0.49 to 5.80) but were more likely to publish peer-reviewed manuscripts (OR = 3.92, 95% CI = 2.25 to 6.83). CONCLUSIONS: Compared to 3-year residency graduates, graduates of our 4-year curriculum were more likely to obtain nonfellowship academic appointments and leadership positions immediately after graduation and to publish their scholarly work during residency. This study suggests that residency applicants seeking to be academically productive during residency and leaders in the field of EM should consider training in a 4-year program with similar goals.

Characterization and impact of COVID-19-tested and infected patients: Experience of The Johns Hopkins Health System Regional Emergency Departments.

BACKGROUND: There is limited understanding of the characteristics and operational burden of persons under investigation (PUIs) and those testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presenting to emergency departments (EDs). METHODS: We reviewed all adult ED visits to 5 Johns Hopkins Health System hospitals in the Maryland/District of Columbia (DC) region during the initial coronavirus disease 2019 (COVID-19) surge, analyzing SARS-CoV-2 polymerase chain reaction test eligibility, results, demographics, acuity, clinical conditions, and dispositions. RESULTS: Of 27,335 visits, 11,402 (41.7%) were tested and 2484 (21.8%) were SARS-CoV-2 positive. Test-positive rates among Hispanics, Asians, African Americans/Blacks, and Whites were 51.6%, 23.7%, 19.8%, and 12.7% respectively. African American/Blacks infection rates (25.5%-33.8%) were approximately double those of Whites (11.1%-21.1%) in the 3 southern Maryland/DC EDs. Conditions with high test-positive rates were fever (41.9%), constitutional (36.4%), upper respiratory (36.9%), and lower respiratory (31.2%) symptoms. Test-positive rates were similar in all age groups (19.9% to 25.8%), although rates of hospitalization increased successively with age. Almost half, 1103 (44.4%), of test-positive patients required admission, of which 206 (18.7%) were to an ICU. CONCLUSION: The initial surge of SARS-CoV-2 test-positive patients experienced in a regional hospital system had ≈ 42% of patients meeting testing criteria and nearly one-fifth of those testing positive. The operational burden on ED practice, including intense adherence to infection control precautions, cannot be understated. Disproportionately high rates of infection among underrepresented minorities underscores the vulnerability in this population. The high rate of infection among self-identified Asians was unexpected.