Emergency department clinical performance of ADVIA Centaur n-terminal prohormone of B-type natriuretic peptide assay.

BACKGROUND: Natriuretic peptide testing is guideline recommended as an aid to the diagnosis of heart failure (HF). We sought to evaluate the performance of the ADVIA Centaur (Siemens Healthcare Diagnostics, Tarrytown, NY) NT-proBNPII assay (PBNPII) in emergency department (ED) dyspneic patients. METHODS: Eligible patients presented to the ED with dyspnea, with their gold standard diagnosis determined by up to 3 cardiologists blinded to the PBNPII results. Patients were stratified into 3 groups based on PBNPII resultsa rule out group of NT-proBNP<300  pg/mL, an age-specific rule in group using cutoffs of 450, 900, and 1800 pg/mL, for <50, 50-75, and > 75 years respectively, and an intermediate cohort for results between the rule out and rule in groups. RESULTS: Of 3128 eligible patients, 1148 (36.7 %) were adjudicated as acute heart failure (AHF). The gold standard AHF diagnosis rate was 3.7, 24.3, and 67.2 % for patients with NTproBNPII in the negative, indeterminate, and positive groups, respectively. Overall likelihood ratios (LR) were 0.07 (95 % CI: 0.05,0.09), 0.55 (0.45,0.67), and 3.53 (3.26,3.83) for the same groups, respectively. Individual LR+for age dependent cutoffs were 5.01 (4.25,5.91), 3.71 (3.25,4.24), and 2.38 (2.10,2.69), respectively. NTproBNPII increased with increasing severity of HF when stratified by NYHA classification. CONCLUSIONS: The ADVIA Centaur PBNPII assay demonstrates acceptable clinical performance using the recommended single rule out and age dependent rule in cutoffs for an AHF diagnosis in dyspneic ED patients.

Development of an Emergency Department Safety Checklist through a global consensus process.

Emergency departments (EDs) are at high risk for medical errors. Checklist implementation programs have been associated with improved patient outcomes in other high-risk clinical settings and when used to address specific aspects of ED care. The aim of this study was to develop an ED Safety Checklist with broad applicability across different international ED settings. A three-round modified Delphi consensus process was conducted with a multidisciplinary and multinational panel of experts in emergency medicine and patient safety. Initial checklist items were identified through a systematic review of the literature. Each item was evaluated for inclusion in the final checklist during two rounds of web-based surveys and an online consensus meeting. Agreement for inclusion was defined a priori with a threshold of 80% combined agreement. Eighty panel members from 34 countries across all seven world regions participated in the study, with comparable representation from low- and middle-income and high-income countries. The final checklist contains 86 items divided into: (1) a general ED Safety Checklist focused on diagnostic evaluation, patient reassessment, and disposition and (2) five domain-specific ED Safety Checklists focused on handoff, invasive procedures, triage, treatment prescription, and treatment administration. The checklist includes key clinical tasks to prevent medical errors, as well as items to improve communication among ED team members and with patients and their families. This novel ED Safety Checklist defines the essential elements of high-quality ED care and has the potential to ensure their consistent implementation worldwide.

Author Response: Outcome Predictors of an Intracerebral Hemorrhage also Depend on the Causes of the Bleeding.

How to cite this article: Hazra D. Author Response: Outcome Predictors of an Intracerebral Hemorrhage also Depend on the Causes of the Bleeding. Indian J Crit Care Med 2024;28(9):892-893.

Prevalence and Outcomes of Carbamazepine Toxicity in the Emergency Department: A Single-center Retrospective Study.

Background: Carbamazepine (CBX) is widely used for various medical conditions, but its associated toxicity poses significant clinical concerns. This study aims to provide insights into the clinical presentations, management strategies, and outcomes of CBX toxicity cases in an emergency department (ED) setting. Methodology: This was a 10-year retrospective cohort chart review study, including all patients with elevated CBX levels. Data on clinical features, CBX levels, laboratory findings, electrocardiograms (ECGs), patient management, and outcomes were analyzed. Cases were categorized as acute or chronic toxicity. Results: Out of the 1,965 medical charts reviewed, we included 70 patients with CBX levels above the therapeutic range (prevalence: 3.6%). Chronic CBX toxicity cases (55.7%) were predominant, with gastrointestinal (GI) symptoms being the most common. Most patients presented with isolated CBX overdoses (88.6%), while mixed overdoses (11.4%) were less frequent. Patients were categorized based on CBX levels: 44 had mild toxicity (>51 µmol/L), and 26 had moderate toxicity (>85 µmol/L). Within the mild group, 15 patients experienced acute toxicity, compared to 16 patients in the moderate group. Four patients who had mixed overdoses and low sensorium required intubation and mechanical ventilation. Three patients received activated charcoal (AC), and another 3 patients received multiple doses of AC to reduce drug absorption. The majority of patients (65.7%) required hospital admission, underscoring the seriousness of CBX toxicity. There were no fatalities among these 70 patients. Conclusion: This study emphasizes the importance of a systematic approach to assessing and managing CBX toxicity, considering its diverse clinical presentations and variations in serum CBX levels. How to cite this article: Hazra D, Ellouze NF, Abri SA. Prevalence and Outcomes of Carbamazepine Toxicity in the Emergency Department: A Single-center Retrospective Study. Indian J Crit Care Med 2024;28(9):866-870.

Disparities in pain management among transgender patients presenting to the emergency department for abdominal pain.

OBJECTIVE: Transgender and gender-diverse (TGD) individuals have a gender identity or expression that differs from the sex assigned to them at birth. They are an underserved population who experience health care inequities. Our primary objective was to identify if there are treatment differences between TGD and cisgender lesbian/gay/bisexual/queer (LGBQ) or heterosexual individuals presenting with abdominal pain to the emergency department (ED). METHODS: Retrospective observational cohort study of patients ≥12 years of age presenting to 21 EDs within a health care system with a chief complaint of abdominal pain between 2018 and 2022. TGD patients were matched 1:1:1:1 to cisgender LGBQ women and men and cisgender heterosexual women and men, respectively. Propensity score matching covariates included age, ED site, mental health history, and gastrointestinal history. The primary outcome was pain assessment within 60 min of arrival. The secondary outcome was analgesics administered in the ED. RESULTS: We identified 300 TGD patients, of whom 300 TGD patients were successfully matched for a total cohort of 1300 patients. The median (IQR) age was 25 (20-32) years and most patients were treated in a community ED (58.2%). There was no difference between groups in pain assessment within 60 min of arrival (59.0% TGD vs. 63.2% non TGD, p = 0.19). There were no differences in the number of times pain was assessed (median [IQR] 2 [1-3] vs. 2 [1-4], p = 0.31) or the severity of pain between groups (5.5 [4-7] vs. 6 [4-7], p = 0.11). TGD patients were more likely to receive nonsteroidal anti-inflammatory drugs (32.0% vs. 24.9%, p = 0.015) and less likely to receive opioids than non-TGD patients (24.7% vs. 36.9%, p = <0.001). TGD and nonbinary patients, along with LGBQ cisgender women (24.7%) and heterosexual cisgender women (34%), were less likely to receive opioids than LGBQ cisgender men (54%) and heterosexual cisgender men (42.3%, p < 0.01). CONCLUSION: There was no difference in frequency of pain assessment, regardless of gender identity or sexual orientation. More cisgender men, compared to TGD and cisgender women, received opioids for their pain.

The effectiveness of parenteral agents to mitigate relapses after severe acute migraine headache presentations: A systematic review and network analysis.

OBJECTIVES: To compare the effectiveness of parenteral agents to reduce relapse in patients with acute migraine and identify factors that predict relapse. BACKGROUND: Following discharge from emergency settings, many patients with acute migraine will experience a relapse in pain; severe relapses may result in re-visits to emergency settings. METHODS: A comprehensive literature search, updated to 2023, was conducted to identify randomized controlled trials assessing the effectiveness of parenteral agents on relapse outcomes in patients with acute migraine discharged from emergency settings. Two independent reviewers completed study selection, quality assessment, and data extraction. A traditional meta-analysis compared parenteral corticosteroids to placebo; a frequentist network analysis assessed direct and indirect comparisons. Results are reported as risk ratios (RRs) and 95% confidence intervals (CIs). The review protocol was registered with the International Prospective Register of Systematic Reviews (identifier: CRD42018099493). RESULTS: From 8949 citations, a total of 53 unique studies were included involving 6167 patients. Most studies had a high or unclear risk of bias. Corticosteroids significantly reduced relapses compared to placebo (RR 0.67, 95% CI 0.52-0.88; I2 = 0%). Patients receiving lidocaine (RR 0.10, 95% CI 0.01-0.82), sedatives/hypnotics (RR 0.33, 95% CI 0.14-0.75), ergot agents (RR 0.44, 95% CI 0.25-0.75), neuroleptics (RR 0.47, 95% CI 0.31-0.71), opioids (RR 0.58; 95% CI 0.35-0.94), or corticosteroids (RR 0.64, 95% CI 0.47-0.86) were significantly less likely to relapse. Lidocaine (RR 0.09, 95% CI 0.01-0.71), combination therapy (RR 0.12, 95% CI 0.02-0.74), or adding corticosteroids (RR 0.61, 95% CI 0.44-0.84) were more likely to reduce severe relapses. Longer duration of headache and residual pain at discharge were significantly associated with higher relapses. DISCUSSION: Corticosteroids remain the recommended first-line option to reduce relapse outcomes. Some parenteral agents typically provided for pain relief including ergot agents, neuroleptics, or combination therapy may effectively reduce relapse; however, opioids are not recommended due to safety concerns. Additional research is needed for some lesser studied, albeit promising, agents including lidocaine and propofol. Effective pain control in emergency settings prior to discharge and duration of headache may play a role in the success of such treatments and further investigations could provide further insight regarding how and why some parenteral agents are effective in mitigating relapse events.

Concordance between risk scales for venous thromboembolism in patients treated in emergency departments. / Concordancia entre las escalas de valoración del riesgo de tromboembolismo venoso en pacientes con patología médica en urgencias.

OBJECTIVE: To evaluate agreement between risk-assessment models for venous thromboembolism (VTE) in patients hospitalized for medical conditions and to analyze variables associated with the decision to prescribe pharmacological thromboprophylaxis in hospital emergency departments (EDs). Conclusions. METHODS: Prospective observational multicenter cohort study. We included adults attended in 15 hospital EDs who were hospitalized for medical conditions, calculating VTE risk according to the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) score, the Padua Prediction Score (PPS), and the National Institute for Health and Care Excellence (NICE) score. In addition to assessing interscore concordance, we analyzed variables associated with the prescription of thromboprophylaxis in the ED. RESULTS: A total of 1203 patients were included. The PADUA, IMPROVE, and NICE scales assigned high risk scores for 68.7%, 47.4%, and 69.5% of the patients, respectively. The κ statistic for agreement between the PADUA and NICE scores was 0.80 (95% CI, 0.76-0.84); 102 patients (8.5%) had discordant scores. The κ statistics for agreement between the IMPROVE score and the PADUA and NICE classifications were 0.47 (95% CI, 0.43-0.52) and 0.37 (95% CI, 0.33-0.42), respectively; 322 (26.8%) and 384 patients (31.9%), respectively, had discordant scores. Variables associated with starting thromboprophylaxis in the ED were a diagnosis of acute myocardial infarction or stroke (adjusted odds ratio [aOR], 4.26), immobility in the last 2 months (aOR, 2.19), chronic obstructive pulmonary disease (aOR, 1.97), ischemic heart disease (aOR, 1.51), reduced mobility of 3 days or longer (aOR, 1.14), body mass index (aOR, 1.04), age (aOR, 1.02), recent trauma or surgery (aOR, 0.40), and risk for bleeding (aOR, 0.56). CONCLUSIONS: There is disagreement among the recommended models for predicting risk for VTE in patients hospitalized for medical conditions. The basis for emergency physicians' clinical judgment regarding thromboprophylaxis extends beyond risk scales to include multiple risk factors for VTE and bleeding.

OBJETIVO: Evaluar la concordancia entre las escalas de riesgo de enfermedad tromboembólica venosa (ETV) de pacientes médicos hospitalizados y analizar las variables asociadas a la decisión de instaurar tromboprofilaxis farmacológica en los servicios de ur gencias(SUH). METODO: Se trata de un estudio de cohorte observacional prospectivo multicéntrico que incluyó pacientes adultos atendidos en 15 SUH españoles que requerían ingreso por patología médica. Se calculó la puntuación según las escalas IMPROVE, PADUA y NICE. Se evaluó la concordancia entre ellas, y las variables asociadas a la indicación de tromboprofilaxis en urgencias. RESULTADOS: Se incluyeron 1.203 pacientes. Las escalas PADUA, IMPROVE y NICE clasificaron de riesgo alto al 68,7%, 47,4% y 69,5% de los pacientes, respectivamente. PADUA y NICE mostraron un índice Kappa de 0,80 (IC 95%: 0,76-0,84) y discordancia del 8,5% (102 pacientes). IMPROVE con PADUA y NICE mostró un índice Kappa de 0,47 (IC 95%:0,43-0,52) y 0,37 (0,33-0,42), con una discordancia del 26,8% (322 pacientes) y 31,9% (384 pacientes), respectivamente. Las variables asociadas con la instauración de tromboprofilaxis fueron infarto agudo de miocardio o ictus (odss ratio ajustada ­ORa­ 4,26), inmovilidad 2 meses previos (ORa 2,19), enfermedad pulmonar obstructiva crónica (ORa 1,97), cardiopatía isquémica (ORa 1,51), movilidad reducida $ 3 días (ORa 1,14), índice masa corporal (ORa 1,04), edad (ORa 1,02), trauma o cirugía recientes (ORa 0,40) y factores de riesgo hemorrágicos (ORa 0,56). CONCLUSIONES: Existe disconcordancia entre las escalas recomendadas para valorar el riesgo de ETV en pacientes médicos hospitalizados. El juicio clínico del urgenciólogo para decidir la tromboprofilaxis se basa en la presencia de múltiples factores de riesgo de ETV y sangrado, más allá de las escalas.

Impact of an emergency department nurse training intervention on the adequacy of thromboprophylaxis for venous thromboembolism: the PROTESU III study. / Impacto de una intervención formativa en enfermería de urgencias sobre la adecuación de la profilaxis de la enfermedad tromboembólica venosa: estudio PROTESU III.

OBJECTIVE: Objectives. To assess the impact of training for emergency department (ED) nurses on adequate thromboprophylaxis for patients admitted to hospital from the ED for medical conditions. Methods. Multicenter quasiexperimental pre-post study of an ED nurse training intervention in 8 hospitals. Patients were recruited from January 2022 through May 2023 in 3 phases: before nurse training, in the first month after training, and in the sixth month after training. Included were patients attended in the ED for medical conditions. Adequate thromboprophylaxis was defined as 1) use of prophylactic drugs in patients at high risk for venousthromboembolism according to the Padua Prediction Score (PPS), and 2) nonuse in patients at low risk. We compared the percentage of adequate prophylaxis in the first phase to the percentages in the second and third phases. Results. A total of 928 patients were included (326 in phase 1, 295 in phase 2, and 307 in phase 3). PPS scores indicated that 238 (73%) of the patients were at high risk in phase 1 vs 189 (64.1%, P = .016) in phase 2 and 207 (67.4%, P = .125) in phase 3. A total of 187 patients (57.4%, 95% CI, 51.8%-62.8%) were adequatelythromboprophylaxed in phase 1 vs 178 (60.%, 95% CI, 54.5%-66%) in phase 2 (absolute difference in proportions, 3.0% (95% CI, -4.8% to 10.6%; P = .462)]. In phase 3, 166 patients (54.1%, 95% CI, 48.3%-59.7%) received adequate prophylaxis (difference, -3.3% (95% CI, -11.0% to 4.4%; P = .405). Conclusions. A training intervention for ED nurses, implemented as an isolated strategy, had no impact on the adequacy of thromboprophylaxis in patients admitted from the ED for medical conditions.

OBJETIVO: Objetivos. Evaluar el impacto de una intervención formativa en enfermería de urgencias sobre la adecuación de la tromboprofilaxis farmacológica de los pacientes ingresados por patología médica. Método. Estudio cuasiexperimental, multicéntrico (8 hospitales), pre y posintervención, con 3 fases de reclutamiento (enero 2022-mayo 2023): primera,preintervención; segunda, en el primer mes tras la intervención; y tercera, al sexto mes. Se incluyeron los pacientes atendidos en urgencias que requirieron ingreso por enfermedad médica. La adecuación de la tromboprofilaxis farmacológica se definió como: 1) la utilización en pacientes clasificados en el grupo de riesgo alto por la Escala de Padua (PPS); o 2) la no utilización en pacientes clasificados de riesgo bajo. Se compararon los porcentajes de adecuación de las fases 2 y 3 frente a la fase 1. Resultados. Se incluyeron 928 pacientes: 326 en la fase 1; 295 en la fase 2; y 307 en la fase 3. En la fase 1, 238 pacientes (73%) fueron clasificados de riesgo alto por PPS; en la fase 2, 189 (64,1%) (p = 0,016); y en la fase 3, 207 (67,4%) (p = 0,125). La tromboprofilaxis farmacológica fue adecuada en 187 pacientes (57,4%, IC 95% 51,8-62,8%) de la fase 1; en 178 (60,3%, IC 95% 54,5 66%) de la fase 2 [diferencia absoluta proporciones (DAP) 3,0% (IC 95% de ­4,8 a +10,6%), p = 0,462], y en 166 (54,1%, IC 95% 48,3-59,7%) de la fase 3 [DAP 3,3% (IC 95% de ­11,0 a +4,4%, p = 0,405]. Conclusiones. Una intervención formativa aislada en la enfermería de urgencias no tuvo impacto sobre la adecuación de la tromboprofilaxis farmacológica en urgencias de los pacientes que ingresan por enfermedad médica.

Hepatitis C virus detection in hospital emergency departments. / Detección de la hepatitis C en los servicios de urgencias hospitalarios.

TEXT: The prevalence of active hepatitis C virus (HCV) infection is higher in hospital emergency departments (EDs) than in the general population. Numerous patients who seek emergency care are unaware that they have detectable viremia, yet they fall outside established ED protocols for HCV screening. Often they belong to groups with difficult access to health care who use the ED as their point of entry to the system. The aim of this consensus paper was to develop an approach to guide ED detection of HCV infection in all Spanish hospitals. Experts from the Spanish Society of Emergency Medicine (SEMES), the Spanish Association for Study of the Liver (AEEH), and the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) met to establish criteria to guide health care professionals' decisions. The experts' review of the literature and discussion in consensus-building meetings resulted in evidence-based recommendations that consider the following aspects: 1) the population to target for HCV screening in the ED, 2) how to inform patients of the process, 3) how to carry out HCV screening, 4) how to order an HCV test, and 5) additional issues such as bundling HCV with other viral tests for comprehensive diagnosis, recording results in medical records, and implementing ways to retain and follow all patients with positive results. This consensus report provides guidelines and tools to facilitate emergency physicians' work and ensure effective detection of HCV infections and subsequent incorporation of patients into the health care system.

TEXTO: La prevalencia de la infección activa por el virus de la hepatitis C (VHC) en los servicios de urgencias hospitalarios (SUH) es superior a la de la población general. Muchos pacientes, desconocedores de su estado de infección y atendidos en urgencias, no cumplen con los criterios establecidos para el cribado del VHC o, muchas veces, son poblaciones de difícil acceso para el sistema sanitario, cuyo único vínculo de entrada son los SUH. Este documento tiene por objetivo elaborar una estrategia que sirva de guía para la detección de VHC en los SUH, de forma que homogenice el abordaje de la infección en todos los hospitales españoles. Un grupo de expertos de la Sociedad Española de Urgencias y Emergencias (SEMES), la Asociación Española para el Estudio del Hígado (AEEH) y la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), se reunieron para establecer los criterios que orienten las decisiones de los profesionales sanitarios. Estos se basan en la evidencia científica identificada mediante una revisión bibliográfica, y consensuada en reuniones deliberativas posteriores. Los aspectos abordados son: 1) población diana para la detección del VHC que acude al SUH; 2) información al paciente; 3) realización de la prueba del VHC; 4) solicitud de la prueba del VHC; y 5) otras consideraciones (diagnóstico integral de otras infecciones, registro de la prueba en la historia clínica y estrategias de vinculación y seguimiento). Este consenso proporciona pautas y herramientas para facilitar la labor del urgenciólogo y garantiza la detección efectiva del VHC y la subsiguiente vinculación al sistema sanitario.

A Lethality Assessment Program in the Emergency Department: Program Implementation and Evaluation.

INTRODUCTION: Despite routine screening for intimate partner violence and validated screening tools for lethality, intimate partner violence assessment and linkage to services remain inconsistent in health care settings. This program aimed to implement and evaluate a lethality assessment program, a nurse-led screening and prevention program for intimate partner violence homicide in an emergency department that partnered with a local community agency. METHODS: A single group pre-post design was used to evaluate changes in knowledge of intimate partner violence and the lethality assessment program protocol and confidence in implementing the protocol among 143 registered nurses in the emergency department. Program outcomes were assessed during a 4-month post-implementation period. Focus group interviews were conducted and analyzed to identify barriers and facilitators of implementation. RESULTS: Significant improvements in the nurses' knowledge and confidence in implementing the protocol (all P< .001) were observed. Fourteen lethality screens were completed during the 4 months, with 13 indicating high intimate partner violence homicide danger. Eight victims received 20 services (1-5/person) from the local community organization: emergency shelter, safety planning, legal aid, and domestic violence protection order. Barriers to implementation included time, privacy, training, and access to screening forms. Facilitators included champions, resources to allow for implementation, and prompts. DISCUSSION: The lethality assessment program is a feasible protocol in a health care setting to increase intimate partner violence awareness, link high-risk intimate partner violence victims to needed services in real time, and potentially reduce intimate partner violence homicides. Programs like this are essential to address this public health concern.

Performance of the 4C and SEIMC scoring systems in predicting mortality from onset to current COVID-19 pandemic in emergency departments.

The evolution of the COVID-19 pandemic has been associated with variations in clinical presentation and severity. Similarly, prediction scores may suffer changes in their diagnostic accuracy. The aim of this study was to test the 30-day mortality predictive validity of the 4C and SEIMC scores during the sixth wave of the pandemic and to compare them with those of validation studies. This was a longitudinal retrospective observational study. COVID-19 patients who were admitted to the Emergency Department of a Spanish hospital from December 15, 2021, to January 31, 2022, were selected. A side-by-side comparison with the pivotal validation studies was subsequently performed. The main measures were 30-day mortality and the 4C and SEIMC scores. A total of 27,614 patients were considered in the study, including 22,361 from the 4C, 4,627 from the SEIMC and 626 from our hospital. The 30-day mortality rate was significantly lower than that reported in the validation studies. The AUCs were 0.931 (95% CI: 0.90-0.95) for 4C and 0.903 (95% CI: 086-0.93) for SEIMC, which were significantly greater than those obtained in the first wave. Despite the changes that have occurred during the coronavirus disease 2019 (COVID-19) pandemic, with a reduction in lethality, scorecard systems are currently still useful tools for detecting patients with poor disease risk, with better prognostic capacity.

Evolving Dynamics of Relational Coordination: A Study of Progression of Care Huddles in Hospital Observation Services.

Health care organizations are increasingly using team huddles to enhance communication, improve patient experience, and deliver timely care. However, established practices, resource constraints, and hierarchical role dynamics can hinder the effectiveness of huddling. This study investigates the dynamics of care huddle implementation through interviews with care providers and managers of an observation unit in a U.S. hospital. Qualitative analysis of interview data reveals that huddle adoption enhances relational coordination (RC), thus highlighting the importance of both coaching interventions in fostering proactive behavior and the building of a work environment aligned toward shared goals. The findings affirm RC as a dynamic change model, examining its interplay with organizational processes and structure. The study underscores the significance of adaptations in work processes, the role of informal boundary spanners in facilitating cross-departmental coordination, and structural changes that increase autonomy for low-power actors. We offer actionable recommendations for health care organizations aiming to improve care coordination.

'Where is the diversity in this facility?' Experiences of emergency care among visible minority individuals in Kingston, Ontario.

INTRODUCTION: Visible minorities, a growing segment of Canada's population, have voiced concerns about experiencing racism while receiving care in the emergency department (ED). Understanding the ED care experiences of visible minorities is crucial to improving care and reducing health disparities. METHODS: From June to August 2021, we collected data from participants in Kingston, Ontario using a sensemaking approach. Individuals who had accessed emergency care or accompanied someone else to the ED in the prior 24 months were eligible to participate. After sharing a brief narrative about their care experience, participants interpreted the experience by plotting their perspectives on a variety of pre-determined questions. Here, we conducted a thematic analysis of narratives involving patients who identified as visible minorities and complemented it with quantitative analysis of the participants' interpretative responses. This mixed-methods approach highlighted the distinct experiences of visible minority participants in relation to a comparison group. RESULTS: Of the 1973 unique participants, 117 identified as a visible minority and 949 participants did not identify with an equity-deserving group (comparison group). Visible minority participants were more likely to report that too little attention was paid to their identity and more likely to express a desire for a balance between receiving the best medical care and being treated with kindness and respect. Visible minorities' ED experiences were also more likely to be impacted by how emergency staff behaved. Qualitative analysis revealed negative experiences of feeling uninformed and disempowered, facing judgement and discrimination, and experiencing language barriers. Positive experiences of receiving compassionate care from staff also emerged. CONCLUSION: Visible minority perceptions of ED care were often negative and mainly focused on staff treatment. Cultural competency and language translation services are key areas for improvement to make ED care more accessible and equitable.

Retrospective Cohort Analysis of the Relationship Between Emergency Department Length of Stay and Timing of First Laboratory Orders.

Background The efficiency of patient management in the Emergency Department (ED) is critical for optimizing healthcare delivery. Provider in triage (PIT) and similar ED flow models attempt to expedite throughput by decreasing the amount of time between patient arrival and initial order placement. The exact relationship between ED length of stay (LOS) and the timing of the first laboratory order, however, is unclear. The varying speed at which clinicians of different ages place laboratory orders and move patients through an ED also is understudied.  Methods A retrospective analysis was conducted using SQL from the Clarity data archive to pull all patient encounters in 2023. Linear regression models using Analysis ToolPak in Microsoft Excel were used to create and examine the relationship between LOS and the timing of the first laboratory order. Secondary outcomes using the same models were created to analyze the impact of clinician age on LOS and the relationship between clinician age and the timing of first laboratory orders.  Results Two hundred sixty-nine thousand eight hundred and eight ED visits were reviewed across three academic and 17 community emergency departments. We report a weak but statistically significant positive relationship between the timing of the first laboratory order and LOS (R² = 0.0378, p < 0.001). Secondary outcomes indicated a very weak negative correlation between clinician age and LOS (R² ≈ 0, p < 0.001) and no significant relationship between clinician age and the timing of the first laboratory order (R² ≈ 0, p > 0.05). Conclusion The timing of the first laboratory order is a significant, albeit weak, predictor of LOS in the ED. Clinician age has minimal impact on LOS and does not significantly influence the timing of the first laboratory order.

The impact of recreational cannabis legalization on cannabis-related acute care events among adults with schizophrenia.

PURPOSE: Patients with schizophrenia have a higher risk of cannabis use disorder and may be uniquely affected by the legalization of recreational cannabis. This study examined whether cannabis legalization led to changes in acute care utilization among patients with schizophrenia. METHOD: Using linked health administrative data, we included adult patients with schizophrenia in Ontario from October 2015 to May 2021 (n = 121,061). We examined the differences in cannabis, psychosis, and mental health-related emergency department (ED) visits over three periods: pre-legalization, legalization of flowers and herbs (phase 1), and legalization of edibles, extracts, and topicals (phase 2) using interrupted time-series methods. RESULTS: Our study found that phase 1 was associated with decreases in cannabis-related, mental health-related, and cannabis + psychosis-related ED visits among the patients with schizophrenia. Notably, an immediate 25.8% (95% CI 13.8-37.6%) decrease in cannabis-related ED visits was observed in men, and an immediate 18.5% decrease in mental health-related ED visits (95% CI 6.0-31.2%) in women. These decreases were also shown in the comparative ITS models, demonstrating that the changes observed were distinct from trends in the general population. However, phase 2 was not associated with any significant changes. CONCLUSIONS: Despite higher baseline rates of acute care utilization among patients with schizophrenia, cannabis legalization was associated with significant reductions, particularly during phase 1. Our findings suggest that regulatory measures accompanying legalization could enhance the quality and safety of cannabis products, potentially leading to fewer adverse health outcomes in vulnerable patient populations. Further research is needed to optimize healthcare responses for this vulnerable population.

Ambulance offload performance, patient characteristics and disposition for patients offloaded to different areas of the emergency department.

OBJECTIVE: Ambulance transfer of care (TOC) is a key performance indicator for New South Wales EDs, with 90% of ambulances to be offloaded within 30 min of arrival. Nepean Hospital ED has a number of strategies to improve TOC, including ambulatory areas where patients can be offloaded immediately. Offload data are supplied by ambulance and there is no study into its accuracy. The aim is to audit the accuracy of ambulance data of TOC compared to times recorded in the Nepean ED information system, and to examine TOC and patient demographics for different offload destinations. METHODS: A retrospective observational study was performed for patients presenting by ambulance between 1 July and 31 December 2022. TOC was calculated from FirstNet and compared to ambulance data using a paired-sample t test. Patients were categorised by offload destination within the ED and examined for age, TOC, disposition and specialty team if admitted. RESULTS: TOC for ambulance and ED data was 60.8% versus 64.1%, respectively (difference 3.33%, P < 0.001). Patients offloaded to acute care were older, with 61.9% being >65 years; had a TOC of 37.3% compared to the resuscitation and ambulatory areas with TOC close to 90%; and were likely to be admitted with a 63.8% admission rate and 24.1% of admissions being under the geriatric service. CONCLUSION: Patients arriving by ambulance requiring an acute care bed were likely to be elderly and frail, and suffered substantial ambulance offload delays. Delays to ambulance offload for these patients is likely driven by acute care bed availability and access block.

Viral Determinants of Childhood Asthma Exacerbation Severity and Treatment Response.

BACKGROUND: Although respiratory viruses are common triggers of asthma exacerbations, the influence of viral infection characteristics on exacerbation presentation and treatment response in the pediatric emergency department (ED) is unclear. OBJECTIVE: To assess viral infection characteristics of children experiencing ED asthma exacerbations and to test their associations with severity and treatment response. METHODS: Prospective study of children, 4-18 years, who received standard ED asthma exacerbation treatment with inhaled bronchodilators and systemic corticosteroids. Nasal swabs collected for viral metagenomic analyses determined virus presence, load and species. Outcomes included exacerbation severity (Pediatric Asthma Severity (PAS) score, clinician impression, and vital signs) and treatment response (discharge home without needing additional asthma therapies). RESULTS: Of 107 children, 47% had moderate/severe exacerbations by PAS and 64% demonstrated treatment response. Viral metagenomic analysis on nasal swabs from 73 children detected virus in 86%, with 10 different species identified, primarily rhinovirus A (RV-A), RV-C, and enterovirus D68. Exacerbations involving RV-A were milder (odds ratio [OR]=0.25; 95% CI=0.07-0.83) and tended to be more responsive to treatment compared to non-RV-A infections, whereas exacerbations involving enterovirus D68 were more severe (OR=8.3; 95% CI=1.3-164.7) and had no treatment response association. Viral load was not associated with treatment response but exhibited a strong linear relationship with heart rate (rpartial=0.48), respiratory rate (rpartial=0.25), and oxygen saturation (rpartial=-0.25), indicative of severity. CONCLUSIONS: The majority of ED asthma exacerbations are triggered by respiratory viruses. Viral species are associated with severity and treatment response, suggesting early pathogen detection could inform ED treatment decisions. Additional studies are needed to identify differences in pathobiology underlying exacerbations triggered by different viral species, and how to effectively treat these heterogeneous exacerbations.

Implementation of an early attention strategy to reduce emergency room overcrowding in an academic institution in Colombia, a pilot study.

Overcrowding is a worldwide problem, and long waiting times are associated with increased morbidity and even mortality of patients regardless of triage classification. Although there are many tools published in the literature that contribute to the reduction of overcrowding, for the Colombian population there are not many tools evaluated to reduce the length of stay of patients in the emergency department. This is a retrospective analytical study that compared whether there was a difference in patient definition time and ED length of stay between a group attended under an early care protocol (PAT) versus the usual protocol. Of the total of 969 patients included it was found that the group attended under the PAT protocol had a shorter definition time than the usual protocol, also the Emergency department length of stay (EDLOS) was significantly lower in the PAT group compared to the usual protocol. The implementation of the PAT protocol performed by emergency physicians allows a faster contact with the patient by the physician, and leads to a significant reduction of EDLOS, contributing to the reduction of overcrowding in the emergency department.

Neighborhood Socioeconomic Disadvantage and Acute Care Utilization in Washington State Medicaid: A Retrospective Cohort Study.

BACKGROUND: Neighborhood disadvantage has been associated with potentially preventable acute care utilization among Medicare beneficiaries, but this association has not been studied in a Medicaid population, which is important for informing more equitable care and policies for this population. OBJECTIVE: To describe the association between Area Deprivation Index (ADI) and acute care utilization (including potentially preventable utilization) among Medicaid beneficiaries in Washington State. DESIGN: Retrospective cohort study of 100% Medicaid claims. Mixed effects logistic regression was applied to estimate the association between state-level ADI decile and acute care utilization, adjusting for age, sex, self-identified race and ethnicity, Charlson Comorbidity Index, primary spoken language, individual Federal Poverty Level, homelessness, and rurality. Standard errors were clustered at the Census block group level. PARTICIPANTS: 1.5 million unique adult Medicaid beneficiaries enrolled for at least 11 months of a calendar year during the period 2017-2021. MAIN MEASURES: Binary measures denoting receipt of ED visits, low-acuity ED visits, hospitalizations in a calendar year. KEY RESULTS: Increasing levels of neighborhood socioeconomic disadvantage (by ADI decile) were associated with greater odds of any ED visits (adjusted odds ratio (aOR) 1.07, 95% confidence interval (CI) 1.06-1.07), low-acuity ED visits (aOR 1.08, CI 1.08-1.08), and any hospitalizations (aOR 1.02, CI 1.02-1.02). CONCLUSIONS: Among Medicaid beneficiaries, greater neighborhood socioeconomic disadvantage was associated with increased acute care utilization, including potentially preventable utilization. These findings signal potential barriers to outpatient care access that could be amenable to future intervention by health systems and payers.

"New" Psychiatric Emergencies Between Hospital and Territory. Survey Results on the Innovative Protocol Between the Emergency Department and Mental Health Center in Trento.

In 2022, psychiatric condition-related admissions constituted 3.2 per cent of all emergency room admissions in Italy, according to the Ministry of Health's latest mental health report. Psychiatric crises are an increasingly significant portion of emergency department (ED) visits nationwide, with around 1 in 8 visits involving mental health and substance use disorders. Patients facing psychiatric emergencies tend to experience longer lengths of stay and boarding times in the ED, along with higher admission rates compared to those with other medical conditions. Extended boarding times for psychiatric patients in the ED increase their vulnerability to adverse events, such as medication errors, the use of restraints, and assaults. Moreover, the prolonged boarding of psychiatric patients contributes to ED overcrowding, which negatively impacts all ED patients, leading to increased morbidity and mortality due to delays in treatment and preventable errors. One of the most effective strategies to counteract this phenomenon has been the choice of directing psychiatric emergencies that are deferrable or compatible with a territorial crisis management from the Trent ED to the Mental Health Center in the territory. This option, promoted through the application of experimental procedures that are currently in the process of being definitively ratified as official company procedures, has, first and foremost, numerous advantages for psychiatric users, who are received in less medicalized settings that are more attentive to the relational and psychological component, while still having suitable medical and nursing equipment. It also fosters continuity of care with the territorial therapeutic network, allows early interception of situations that are promptly taken care of by the territorial specialist center, and more easily offers treatment alternatives to hospitalization. This approach allows for the optimal utilisation of resources and expertise available at Mental Health Centres within the community, thereby preventing the overcrowding of hospital emergency departments.