Brief Risk Communication for Emergency Department Patients With Sustained Asymptomatic Hypertension.

INTRODUCTION: Sustained asymptomatic hypertension in ED patients is a powerful predictor of chronic uncontrolled hypertension. In this study, we assess the feasibility of using a storyboard video and communicating real-time cardiovascular imaging results on blood pressure control and primary care engagement. METHODS: This was a prospective observational exploratory sub-study. Following Institutional Review Board approval (#18-00197), 20 English-speaking adults in an urban emergency department with an initial blood pressure ≥160/100 mm Hg and a second blood pressure ≥140/90 mm Hg were enrolled. Patients watched a 60-second storyboard video about uncontrolled hypertension in the ED setting, featuring racially and ethnically diverse avatars. They then received a real-time bedside echocardiogram. Emergency nurses communicated the echocardiogram results using a standard script and advised follow-up within 2 weeks after discharge. Patient characteristics, blood pressure control, primary care engagement, and acceptability of the intervention were assessed at baseline, 12 weeks, and 24 weeks post-discharge. RESULTS: All 20 enrolled patients (mean age 55, 70% female, and 95% from underrepresented groups [30% Black, 50% Hispanic, and 15% Black and Hispanic]) exhibited subclinical heart disease on echocardiograms. Blood pressure control improved from baseline (systolic 166 mm Hg, diastolic 97 mm Hg) to 24 weeks (systolic 137 mm Hg, diastolic 78 mm Hg). Seventy percent of patients engaged with primary care post-discharge, and the intervention had high acceptability (94.8% approval). DISCUSSION: The Brief Risk Communication for ED patientswith sustained asymptomatic hypertension study demonstrates the feasibility and acceptability of using a brief video and real-time cardiovascular imaging for risk communication in the emergency department. Future research will build on these findings with a larger, more comprehensive study.

A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care.

The emergency department serves as a vital source of health care for residents in the United States, including as a safety net. However, patients from minoritized racial and ethnic groups have historically experienced disproportionate barriers to accessing health care services and lower quality of services than White patients. Quality measures and their application to quality improvement initiatives represent a critical opportunity to incentivize health care systems to advance health equity and reduce health disparities. Currently, there are no nationally recognized quality measures that track the quality of emergency care delivery by race and ethnicity and no published frameworks to guide the development and prioritization of quality measures to reduce health disparities in emergency care. To address these gaps, the American College of Emergency Physicians (ACEP) convened a working group of experts in quality measurement, health disparities, and health equity to develop guidance on establishing quality measures to address racial and ethnic disparities in the provision of emergency care. Based on iterative discussion over 3 working group meetings, we present a summary of existing emergency medicine quality measures that should be adapted to track racial and ethnic disparities, as well as a framework for developing new measures that focus on disparities in access to emergency care, care delivery, and transitions of care.

"The project did not come to us with a solution": Perspectives of research teams on implementing a study about electronic health record-embedded individualized pain plans for emergency department treatment of vaso-occlusive episodes in adults with sickle cell disease.

BACKGROUND: This study aimed to capture the implementation process of the ALIGN Study, (An individualized Pain Plan with Patient and Provider Access for Emergency Department care of Sickle Cell Disease). ALIGN aimed to embed Individualized Pain Plans in the electronic health record (E-IPP) and provide access to the plan for both adult patients with sickle cell disease (SCD) and emergency department providers when a person with SCD comes to the emergency department in vaso-occlusive crises. METHODS: Semi-structured interviews were conducted with research teams from the 8 participating sites from the ALIGN study. Seventeen participants (principal investigators and study coordinators) shared their perspectives about the implementation of ALIGN in their sites. Data were analyzed in three phases using open coding steps adapted from grounded theory and qualitative content analysis. RESULTS: A total of seven overarching themes were identified: (1) the E-IPP structure (location and upkeep) and collaboration with the informatics team, (2) the role of ED champion, (3) the role of research coordinators, (4) research team communication, and communication between research team and clinical team, (5) challenges with the study protocol, (6) provider feedback: addressing over-utilizers, patient mistrust, and the positive feedback about the intervention, and (7) COVID-19 and its effects on study implementation. CONCLUSIONS: Findings from this study contribute to learning how to implement E-IPPs for adult patients with SCD in ED. The study findings highlight the importance of early engagement with different team members, a champion from the emergency department, study coordinators with different skills and enhancement of communication and trust among team members. Further recommendations are outlined for hospitals aiming to implement E-IPP for patients with SCD in ED.

Survival After Out-of-Hospital Cardiac Arrest: The Role of Racial Residential Segregation.

Racial and racialized economic residential segregation has been empirically associated with outcomes across multiple health conditions but not yet explored in relation to out-of-hospital cardiac arrest (OHCA). We sought to examine if measures of racial and economic residential segregation are associated with differences in survival to discharge after OHCA for Black and White Medicare beneficiaries. Utilizing age-eligible Medicare fee-for-service claims data from 2013 to 2015, we identified OHCA claims and determined survival to discharge. The primary predictor, residential segregation, was calculated using the index of concentration at the extremes (ICE) for the beneficiary residential ZIP code. Multilevel modified Poisson regression models were used to determine the association of OHCA outcomes and ZIP code level ICE measures. In total, 194,263 OHCA cases were identified among beneficiaries residing in 75% of US ZIP codes. Black beneficiaries exhibited 12.1% survival to discharge, compared with 12.5% of White beneficiaries. In fully adjusted models of the three ICE measures accounting for differences in treating hospital characteristics, there was as high as a 28% (RR 1.28, CI 1.23-1.26) higher relative likelihood of survival to discharge in the most segregated White ZIP codes (Q5) as compared to the most segregated Black ZIP codes (Q1). Racial residential segregation is independently associated with disparities in OHCA outcomes; among Medicare beneficiaries who generated a claim after suffering an OHCA, ICE measures of racial segregation are associated with a lower likelihood of survival to discharge for those living in the most segregated Black and lower income quintiles compared to higher quintiles.

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality.

PURPOSE: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. METHODS: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. RESULTS: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. CONCLUSIONS: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Decline in U.S. Emergency Department admission rates driven by critical pathway conditions, 2006-2014.

OBJECTIVES: Despite increasing ED visits, evidence suggests overall hospitalization rates have decreased; however, it is unknown what clinical conditions account for these changes. We aim to describe condition-specific trends and hospital-level variation in hospitalization rates after ED visits from 2006 to 2014. METHODS: Retrospective observational study of adult ED visits to U.S. acute care hospitals using nationally weighted data from the 2006-2014 National Emergency Department Survey. Our primary outcome was ED admission rate, defined as the number of admissions originating in the ED divided by the number of ED visits. We report admission rates overall and for each condition, including changes over time. We used logistic regression to compare the odds of ED admission from 2006 to 2014, adjusting for patient and hospital characteristics. We also measured hospital-level variation by calculating hospital-level median ED admission rates and interquartile ranges. RESULTS: After adjusting for patient and hospital characteristics, the odds of ED admission for any condition were 0.49 (CI 0.45, 0.52) in 2014 compared to 2006. The conditions with the greatest relative change in ED admission rates were chest pain (21.7 to 7.5%) and syncope (28.9 to 13.8%). The decline in ED admission rates were accompanied by increased variation in hospital-level ED admission rates. CONCLUSIONS: Recent reductions in ED admissions are largely attributable to decreased admissions for conditions amenable to outpatient critical pathways. Focusing on hospitals with persistently above-average ED admission rates may be a promising approach to improve the value of acute care.

Cost variation and revisit rate for adult patients with asthma presenting to the emergency department.

BACKGROUND: Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care. STUDY OBJECTIVE: We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation. METHODS: We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering. RESULTS: In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00). CONCLUSION: Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

Prior use of medications for opioid use disorder in ED patients with opioid overdose: prevalence, misuse and overdose severity.

OBJECTIVES: Medications for opioid use disorder (MOUD) reduce opioid overdose (OD) deaths; however, prevalence and misuse of MOUD in ED patients presenting with opioid overdose are unclear, as are any impacts of existing MOUD prescriptions on subsequent OD severity. METHODS: This was a prospective observational cohort of ED patients with opioid OD at two tertiary-care hospitals from 2015 to 19. Patients with confirmed opioid OD (via urine toxicology) were included, while patients with alternate diagnoses, insufficient data, age < 18, and prisoners were excluded. OD severity was defined using: (a) hospital LOS (days); and (b) in-hospital mortality. Time trends by calendar year and associations between MOUD and study outcomes were calculated. RESULTS: In 2829 ED patients with acute drug OD, 696 with confirmed opioid OD were included. Overall, 120 patients (17%) were previously prescribed any MOUD, and MOUD prevalence was significantly higher in 2018 and 2019 compared to 2016 (20.1% and 27.8% vs. 8.8%, p < 0.05). Odds of MOUD misuse were significantly higher for methadone (OR 3.96 95% CI 2.57-6.12) and lowest for buprenorphine (OR 1.16, p = NS). Mean LOS was over 50% longer for methadone (3.08 days) compared to buprenorphine and naltrexone (both 2.0 days, p = NS). Following adjustment for confounders, buprenorphine use was associated with significantly shorter LOS (IRR -0.44 (95%CI -0.85, -0.04)). Odds of death were 30% lower for patients on any MOUD (OR 0.70, 95%CI 0.09-5.72), but highest in the methadone group (OR 0.82, 95%CI 0.10-6.74). CONCLUSIONS: While MOUD prevalence significantly increased over the study period, MOUD misuse occurred for patients taking methadone, and OD LOS overall was lower in patients with any prior buprenorphine prescription.

Provider-Referred Versus Self-Referred Emergency Department Visit After Urgent Care Center Visit.

BACKGROUND: Urgent care centers (UCCs) provide an alternative to emergency departments (EDs) for low-acuity acute care, as they are convenient with shorter wait time, but little is known about the quality of care at UCCs. OBJECTIVE: We described and determined the differences in characteristics of patients who were sent to the ED by UCC physicians (provider-referred) with those of patients who went to the ED on their own (self-referred) within 72 h of discharge after a UCC visit. Our primary objective was to investigate whether observation unit use or hospital admission rates were different between the two groups. Our secondary objective was to identify whether their follow-up ED visits were avoidable. METHODS: We conducted this prospective cohort study between March 22, 2017 and September 30, 2018 in a closed health system. A total of 53,178 UCC visits resulted in 582 provider-referred and 263 self-referred ED visits. We compared the characteristics of the two groups and measured the outcomes of observation unit or hospital admissions. RESULTS: Patients with self-referred ED visits were younger; mean (standard deviation) age was 47.9 (24.5) years. Provider-referred patients appeared to be significantly associated with observation unit or hospital admission (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.24-2.46). Among the predictors for observation unit or hospital admission, consultation with a specialist in the ED was the strongest (adjusted OR 9.09; 95% CI 6.24-13.24); other significant predictors were Medicaid or no insurance. CONCLUSIONS: We found that after an urgent care visit, patients who were sent to the ED by a UCC provider were not more likely than self-referred patients to be admitted to an observation unit or hospital from the ED. Significant predictors for observation unit or hospital admission after UCC discharge were specialist consultation and type of insurance.

GUÍA: a digital platform to facilitate result disclosure in genetic counseling.

PURPOSE: Use of genomic sequencing is increasing at a pace that requires technological solutions to effectively meet the needs of a growing patient population. We developed GUÍA, a web-based application, to enhance the delivery of genomic results and related clinical information to patients and families. METHODS: GUÍA development occurred in five overlapping phases: formative research, content development, stakeholder/community member input, user interface design, and web application development. Development was informed by formative qualitative research involving parents (N = 22) whose children underwent genomic testing. Participants enrolled in the NYCKidSeq pilot study (N = 18) completed structured feedback interviews post-result disclosure using GUÍA. Genetic specialists, researchers, patients, and community stakeholders provided their perspectives on GUÍA's design to ensure technical, cultural, and literacy appropriateness. RESULTS: NYCKidSeq participants responded positively to the use of GUÍA to deliver their children's results. All participants (N = 10) with previous experience with genetic testing felt GUÍA improved result disclosure, and 17 (94%) participants said the content was clear. CONCLUSION: GUÍA communicates complex genomic information in an understandable and personalized manner. Initial piloting demonstrated GUÍA's utility for families enrolled in the NYCKidSeq pilot study. Findings from the NYCKidSeq clinical trial will provide insight into GUÍA's effectiveness in communicating results among diverse, multilingual populations.