Changes in emergency department use in British Columbia, Canada, during the first 3 years of the COVID-19 pandemic.

BACKGROUND: Previous studies have shown reductions in the volume of emergency department visits early in the COVID-19 pandemic, but few have evaluated the pandemic's impact over time or stratified analyses by reason for visits. We aimed to quantify such changes in British Columbia, Canada, cumulatively and during prominent nadirs, and by reason for visit, age and acuity. METHODS: We included data from the National Ambulatory Care Reporting System for 30 emergency departments across BC from January 2016 to December 2022. We fitted generalized additive models, accounting for seasonal and annual trends, to the monthly number of visits to estimate changes throughout the pandemic, compared with the expected number of visits in the absence of the pandemic. We determined absolute and relative differences at various times during the study period, and cumulatively since the start of the pandemic until the overall volume of emergency department visits returned to expected levels. RESULTS: Over the first 16 months of the pandemic, the volume of emergency department visits was reduced by about 322 300 visits, or 15% (95% confidence interval 12%-18%), compared with the expected volume. A sharp drop in pediatric visits accounted for nearly one-third of the reduction. The timing of the return to baseline volume of visits differed by subgroup. The largest and most sustained decreases were in respiratory-related emergency department visits, visits among children, visits among oldest adults and non-urgent visits. Later in the pandemic, we observed increased volumes of highest-urgency visits, visits among children and visits related to ear, nose and throat. INTERPRETATION: We have extended evidence that the impact of the COVID-19 pandemic and associated mitigation strategies on emergency department visits in Canada was substantial. Both our findings and methods are relevant in public health surveillance and capacity planning for emergency departments in pandemic and nonpandemic times.

Which Patients Should Have Early Surgical Intervention for Acute Ureteral Colic?

PURPOSE: Early surgical intervention is an attractive option for acute ureteral colic but existing evidence does not clarify which patients benefit. We compared treatment failure rates in patients receiving early intervention and patients offered spontaneous passage to identify subgroups that benefit from early intervention. MATERIALS AND METHODS: We used administrative data and structured chart review to study consecutive patients attending 9 emergency departments in 2 Canadian provinces with confirmed 2.0 to 9.9 mm ureteral stones. We described patient, stone and treatment characteristics, and performed multivariable regression to identify factors associated with treatment failure, defined as intervention or hospitalization within 60 days. Our secondary outcome was emergency department revisit rate. RESULTS: Overall 1,168 of 3,081 patients underwent early intervention. Those with stones smaller than 5 mm experienced more treatment failures (31.5% vs 9.9%, difference 21.6%, 95% CI 16.9 to 21.2) and emergency department revisits (38.5% vs 19.7%, difference 18.8%, 95% CI 13.8 to 23.8) with early intervention than with spontaneous passage. Patients with stones 7.0 mm or larger experienced fewer treatment failures (34.7% vs 58.6%, risk difference 23.9%, 95% CI 11.3 to 36.6) and similar emergency department revisit rates with early intervention. Patients with 5.0 to 6.9 mm stones had fewer treatment failures with intervention (37.4% vs 55.5%, risk difference 18.1%, 95% CI 7.1 to 28.9) if stones were in the proximal or middle ureter. CONCLUSIONS: Early intervention improves outcomes for patients with large (greater than 7 mm) ureteral stones or 5 to 7 mm proximal or mid ureteral stones. Early intervention may increase morbidity for patients with stones smaller than 5 mm. These findings could help inform future guidelines.

Routine HIV testing in acute care hospitals: Changing practice to curb a local HIV epidemic in Vancouver, BC.

Early treatment of HIV infection increases life expectancy and reduces infectivity; however, delayed HIV diagnosis remains common. Implementation and sustainability of hospital-based routine HIV testing in Vancouver, British Columbia, was evaluated to address a local HIV epidemic by facilitating earlier diagnosis and treatment. Public health issued a recommendation in 2011 to offer HIV testing to all patients presenting to three Vancouver hospitals as part of routine care, including all patients admitted to medical/surgical units with expansion to emergency departments (ED). We evaluated acceptability, feasibility, and effectiveness from 2011 to 2014 and continued monitoring through 2016 for sustainability. Between October 2011-December 2016, 114,803 HIV tests were administered at the three hospitals; an 11-fold increase following implementation of routine testing. The rate of testing was sustained and remained high through 2018. Of those tested, 151 patients were diagnosed with HIV for a testing yield of 0.13%. Review of 12,996 charts demonstrated 4935/5876 (96·9%) of admitted patients agreed to have an HIV test when offered. People diagnosed in hospital were significantly more likely to be diagnosed with acute stage (aOR 1·96, 95% CI 1·19, 3·23) infection, particularly those diagnosed in the ED. This study provides practice-based evidence of the feasibility, acceptability, and effectiveness of implementing a recommendation for routine HIV testing among inpatient and emergency department admissions, as well as the ability to normalize and sustain this change. Routine hospital-based HIV testing can increase diagnoses of acute HIV infection and facilitate earlier initiation of antiretroviral treatment.

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal.

STUDY OBJECTIVE: Alcohol withdrawal is a common emergency department (ED) presentation. Although benzodiazepines reduce symptoms of withdrawal, there is little ED-based evidence to assist clinicians in selecting appropriate pharmacotherapy. We compare lorazepam with diazepam for the management of alcohol withdrawal to assess 1-week ED and hospital-related outcomes. METHODS: From January 1, 2015, to December 31, 2018, at 3 urban EDs in Vancouver, Canada, we studied patients with a discharge diagnosis of alcohol withdrawal. We excluded individuals presenting with a seizure or an acute concurrent illness. We performed a structured chart review to ascertain demographics, ED treatments, and outcomes. Patients were stratified according to initial management with lorazepam versus diazepam. The primary outcome was hospital admission, and secondary outcomes included in-ED seizures and 1-week return visits for discharged patients. RESULTS: Of 1,055 patients who presented with acute alcohol withdrawal, 898 were treated with benzodiazepines. Median age was 47 years (interquartile range 37 to 56 years) and 73% were men. Baseline characteristics were similar in the 2 groups. Overall, 69 of 394 patients (17.5%) receiving lorazepam were admitted to the hospital compared with 94 of 504 patients receiving diazepam (18.7%), a difference of 1.2% (95% confidence interval -4.2% to 6.3%). Seven patients (0.7%; 95% confidence interval 0.3% to 1.4%) had an in-ED seizure, but all seizures occurred before receipt of benzodiazepines. Among patients discharged home, 1-week return visits occurred for 78 of 325 (24.0%) who received lorazepam and 94 of 410 (23.2%) who received diazepam, a difference of 0.8% (95% confidence interval -5.3% to 7.1%). CONCLUSION: In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam. The few in-ED seizures occurred before medication administration. For discharged patients, the 1-week ED return visit rate of nearly 25% could warrant enhanced follow-up and community support.

Paediatric patients seen in 18 emergency departments during the COVID-19 pandemic.

BACKGROUND: Public health mitigation strategies in British Columbia during the pandemic included stay-at-home orders and closure of non-essential services. While most primary physicians' offices were closed, hospitals prepared for a pandemic surge and emergency departments (EDs) stayed open to provide care for urgent needs. We sought to determine whether ED paediatric presentations prior and during the COVID-19 pandemic changed and review acuity compared with seasonal adjusted prior year. METHODS: We analysed records from 18 EDs in British Columbia, Canada, serving 60% of the population. We included children 0-16 years old and excluded those with no recorded acuity or discharge disposition and those left without being seen by a physician. We compared prepandemic (before the first COVID-19 case), early pandemic (after first COVID-19 case) and peak pandemic (during public health emergency) periods as well as a similar time from the previous year. RESULTS: A reduction of 57% and 70% in overall visits was recorded in the children's hospital ED and the general hospitals EDs, respectively. Average daily visits declined significantly during the peak-pandemic period (167.44±40.72) compared with prepandemic period (543.53±58.8). Admission rates increased mainly due to the decrease in the rate of visits with lower acuity. Children with complaints of 'fever' and 'gastrointestinal' symptoms had both the largest overall volume and per cent reduction in visits between peak-pandemic and prior year (79% and 74%, respectively). CONCLUSION: Paediatric emergency medicine attendances were reduced to one-third of normal numbers during the 2020 COVID-19 lockdown in British Columbia, Canada, with the reduction mainly seen in minor illnesses that do not usually require admission.

Safety of a Modified Community Trailer to Manage Patients with Presumed Fentanyl Overdose.

Opioid overdoses (OD) cause substantial morbidity and mortality globally, and current emergency management is typically limited to supportive care, with variable emphasis on harm reduction and addictions treatment. Our urban setting has a high concentration of patients with presumed fentanyl OD, which places a burden on both pre-hospital and emergency department (ED) resources. From December 13, 2016, to March 1, 2017, we placed a modified trailer away from an ED but near the center of the expected area of high OD and accepted low-risk patients with presumed fentanyl OD. We provided OD treatment as well as on-site harm reduction, addictions care, and community resources. The primary outcome was the proportion of patients requiring transfer to an ED for clinical deterioration, while secondary outcomes were the proportion of patients initiated on opioid agonists and provided take-home naloxone kits. We treated 269 patients with opioid OD, transferred three (1.1%) to a local ED, started 43 (16.0%) on opioid agonists, and provided 220 (81.7%) with THN. Our program appears to be safe and may serve as a model for other settings dealing with a large numbers of opioid OD.

Low-impact strategy for capturing better emergency department injury surveillance data.

OBJECTIVES: Injury prevention should be informed by timely surveillance data. Unfortunately, most injury surveillance only captures patients with severe injuries and is not available in real time, hampering prevention efforts. We aimed to develop and pilot a simple injury surveillance strategy that can be integrated into routine emergency department (ED) workflow to collect more robust mechanism of injury information at time of visit for all injured ED patients with minimal impact on workflow. METHODS: We reviewed ED injury surveillance systems and considered ED workflow. Forms were developed to collect injury-related information on ED patients and refined to address workload concerns raised by key stakeholders. Research assistants observed ED staff as they registered injured patients and noted the time required to collect data and any ambiguities or concerns encountered. Interobserver agreement was recorded. RESULTS: Injury surveillance questions were based on a modification of the International Classification of External Causes of Injury. Research assistants observed 222 injured patients being admitted by registration clerks. The mean time required to complete the surveillance form was 64.9 s (95% CI 59.9 s to 69.9 s) for paper-based forms (120 cases) and 44.5 s (95% CI 41.7s to 47.4s) with direct electronic data entry (102 cases). Interobserver agreement (26 cases) was 100% for intent (kappa=1.0) of injury and 96% for mechanism of injury (kappa=0.74). CONCLUSIONS: We report a simple injury surveillance strategy that ED staff can use to collect meaningful injury data in real time with minimal impact on workflow. This strategy can be adapted to enhance regional injury surveillance efforts.

Outcomes From Referrals and Unscheduled Visits From Community Emergency Departments to a Regional Pediatric Emergency Department in Canada.

OBJECTIVES: Existing pediatric literature describing repeat visits to the emergency department (ED) for the same medical complaint has yet to report on patient flow patterns from general EDs (GEDs) to a pediatric ED (PED). We sought to characterize the population of patients who are treated in a GED and subsequently present to a PED for further care. METHODS: We conducted a retrospective cohort study reviewing all pediatric visits (age < 17 y) at 5 GEDs in Vancouver. Our primary outcome measure was the proportion of visits with a subsequent visit to a PED (<7 days) during the 2012 to 2013 fiscal year. Secondary outcomes included reasons for PED consultation, the clinical services accessed, and disposition at the PED. RESULTS: During the study period, 581 (3.3%) of the 17,824 children seen at GEDs subsequently presented to the PED within 7 days. The top 3 diagnoses among these were fracture, viral infection, and musculoskeletal complaints. Of the 581 children with a visit to the PED, 180 (31.0%) were referred to the PED for a consultation, whereas the rest were family initiated. Referred visits were more frequently associated with pediatric subspecialist consultation than family-initiated visits (45.0% vs 19.5%, P < 0.01). The referred group more frequently resulted in a surgical procedure (13.9% vs 2.5%, P < 0.01) or hospital admission (51.7% vs 8.7%, P < 0.01). CONCLUSIONS: Knowing the proportion, management, and outcomes of children who are treated in a GED and subsequently at a PED may provide an important quality measure and opportunities to improve the management of common pediatric emergencies in the community.

Safety of a Brief Emergency Department Observation Protocol for Patients With Presumed Fentanyl Overdose.

STUDY OBJECTIVE: Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose. METHODS: At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs. RESULTS: There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85% were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient died within 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone. CONCLUSION: In our cohort of ED patients with uncomplicated presumed fentanyl overdose-typically after injection-deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged after brief observation. Patients with normal triage vital signs are unlikely to require ED naloxone.

Missed Opportunities for HIV Prophylaxis Among Emergency Department Patients With Occupational and Nonoccupational Body Fluid Exposures.

STUDY OBJECTIVE: Exposures to HIV are frequently managed in the emergency department (ED) for assessment and potential initiation of HIV postexposure prophylaxis. Despite established guidelines, it is unclear whether patients with a nonoccupational exposure are managed similarly to patients with an occupational exposure. METHODS: This retrospective study used an administrative database to identify consecutive patients at a single ED with a discharge diagnosis of "blood or body fluid exposure" without sexual assault from April 1, 2007 to June 30, 2013. Patient exposure details and physician management were ascertained according to predefined guidelines. The primary outcome was the proportion of patients with high-risk exposures who were correctly given HIV prophylaxis; the secondary outcome was the proportion of patients with low-risk exposures who were correctly not given HIV prophylaxis. Other outcomes included the proportion of patients who had a baseline HIV test in the ED, the proportion who followed up with an HIV test within 6 months, and the number of seroconversions in this group. All outcomes were compared between nonoccupational and occupational exposure. RESULTS: Of 1,972 encounters, 1,358 patients (68.9%) had an occupational exposure and 614 (31.1%) had a nonoccupational exposure. In the occupational exposure group, 190 patients (14.0%) were deemed high risk, with 160 (84.2%; 95% confidence interval [CI] 78.1% to 88.9%) appropriately given prophylaxis. In the nonoccupational exposure group, 287 patients (46.7%) had a high-risk exposure, with 208 (72.5%; 95% CI 66.8% to 77.5%) given prophylaxis, for a difference of 11.7% (95% CI 3.8% to 19.1%). For low-risk exposures, appropriate management of both occupational and nonoccupational exposure was similar (92.4% versus 93.0%). At the index ED visit, 90.5% of occupational exposure patients and 76.7% of nonoccupational exposure patients received HIV testing, for a difference of 13.8% (95% CI 10.1% to 17.7%). At 6 months, 25.4% of patients with an occupational exposure and 35.0% of patients with a nonoccupational exposure had a follow-up test, for a difference of -9.6% (95% CI -14.2% to -5.1%). Of patients who had follow-up testing within 6 months, 4 of 215 (1.9%) in the nonoccupational exposure group tested newly positive for HIV, whereas 0 of 345 (0%) in the occupational exposure group tested positive. CONCLUSION: For ED patients with blood or body fluid exposures, those with high-risk nonoccupational exposures were not given HIV prophylaxis nearly twice as often as those with high-risk occupational exposure. Although 6-month follow-up testing rates were low, 1.9% of high-risk nonoccupational exposure patients seroconverted.

Protocol of the impact of alternative social assistance disbursement on drug-related harm (TASA) study: a randomized controlled trial to evaluate changes to payment timing and frequency among people who use illicit drugs.

BACKGROUND: Government social assistance payments seek to alleviate poverty and address survival needs, but their monthly disbursement may cue increases in illicit drug use. This cue may be magnified when assistance is disbursed simultaneously across the population. Synchronized payments have been linked to escalations in drug use and unintended but severe drug-related harms, including overdose, as well as spikes in demand for health, social, financial and police services. METHODS/DESIGN: The TASA study examines whether changing payment timing and frequency can mitigate drug-related harm associated with synchronized social assistance disbursement. The study is a parallel arm multi-group randomized controlled trial in which 273 participants are randomly allocated for six assistance cycles to a control or one of two intervention arms on a 1:1:1 basis. Intervention arm participants receive their payments: (1) monthly; or (2) semi-monthly, in each case on days that are not during the week when cheques are normally issued. The study partners with a community-based credit union that has developed a system to vary social assistance payment timing. The primary outcome is a 40 % increase in drug use during the 3 days beginning with cheque issue day compared to other days of the month. Bi-weekly follow-up interviews collect participant information on this and secondary outcomes of interest, including drug-related harm (e.g. non-fatal overdose), exposure to violence and health service utilization. Self-reported data will be supplemented with participant information from health, financial, police and government administrative databases. A longitudinal, nested, qualitative parallel process evaluation explores participant experiences, and a cost-effectiveness evaluation of different disbursement scenarios will be undertaken. Outcomes will be compared between control and intervention arms to identify the impacts of alternative disbursement schedules on drug-related harm resulting from synchronized income assistance. DISCUSSION: This structural RCT benefits from strong community partnerships, highly detailed outcome measurement, robust methods of randomization and data triangulation with third party administrative databases. The study will provide evidence regarding the potential importance of social assistance program design as a lever to support population health outcomes and service provision for populations with a high prevalence of substance use. TRIAL REGISTRATION: NCT02457949 Registered 13 May 2015.

Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm.

STUDY OBJECTIVE: Although the management and outcomes of emergency department (ED) patients with atrial fibrillation or flutter have been explored, such studies have typically excluded patients with acute underlying medical illnesses. We seek to describe the ED treatment and outcomes of these complex patients with atrial fibrillation or flutter. METHODS: This retrospective descriptive cohort study used an ECG database from 2 urban EDs to identify consecutive ED patients with an ECG demonstrating atrial fibrillation or flutter from January 1, 2009, to December 31, 2009. We categorized patients with atrial fibrillation or flutter as "complex" according to prespecified criteria and then grouped them as being managed with rate or rhythm control attempts, or not. The primary outcome was safety of rate or rhythm control, measured by whether patients had a predefined adverse event or not. The secondary outcome was the success of rate or rhythm control, defined as rate control decreasing the pulse rate by 20 beats/min and successful rhythm control, both within 4 hours of treatment initiation. Descriptive statistics were used to compare the 2 groups. RESULTS: Four hundred sixteen complex patients with atrial fibrillation or flutter were identified. Patients managed with rate or rhythm control were similar in all baseline characteristics and illness distribution to patients who were not managed in this manner. The 135 patients with attempted rate control (105) or rhythm control (30) had 55 adverse events (40.7%; 95% confidence interval [CI] 32.5% to 49.5%), whereas the 281 patients not managed with rate or rhythm control had 20 adverse events (7.1%; 95% CI 4.5% to 10.9%), for a risk difference of 33.6% (95% CI 24.3% to 42.5%) and a relative risk of 5.7 (95% CI 3.6 to 9.1). Twenty of 105 patients (19.1%; 95% CI 12.3% to 28.1%) were successfully rate controlled, whereas 4 of 30 (13.3%; 95% CI 4.4% to 31.6%) were successfully rhythm controlled. CONCLUSION: In ED patients with complex atrial fibrillation or flutter, attempts at rate and rhythm control are associated with a nearly 6-fold higher adverse event rate than that for patients who are not managed with rate or rhythm control. Success rates of rate or rhythm control attempts appear low.

Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses.

STUDY OBJECTIVE: Corticosteroids (steroids) are often used to mitigate symptoms and prevent subsequent reactions in emergency department (ED) patients with allergic reactions, despite a lack of evidence to support their use. We sought to determine the association of steroid administration with improved clinical outcomes. METHODS: Adult allergy-related encounters to 2 urban EDs during a 5-year period were identified and classified as "anaphylaxis" or "allergic reaction." Regional and provincial databases identified subsequent ED visits or deaths within a 7-day period. The primary outcome was allergy-related ED revisits in the steroid- and nonsteroid-exposed groups, adjusting for potential confounders with a propensity score analysis; secondary outcomes included the number of clinically important biphasic reactions and deaths. RESULTS: Two thousand seven hundred one encounters (473 anaphylactic) were included; 48% were treated with steroids. Allergy-related ED revisits occurred in 5.8% and 6.7% of patients treated with and without steroids, respectively (adjusted odds ratio [OR] 0.91; 95% confidence interval [CI] 0.64 to 1.28), with a number needed to treat (NNT) to benefit of 176 (95% CI NNT to benefit 39 to ∞ to NNT to harm 65). The adjusted OR in the anaphylaxis subgroup was 1.12 (95% CI 0.41 to 3.27). In the allergic reaction group, the adjusted OR was 0.91 (95% CI 0.63 to 1.31), with an NNT to benefit of 173 (95% CI NNT to benefit 38 to ∞ to NNT to harm 58). In the steroid and nonsteroid groups, there were 4 and 1 clinically important biphasic reactions, respectively. There were no deaths. CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, corticosteroid use was not associated with decreased relapses to additional care within 7 days.

Factors Influencing the Decision to Attend a Pediatric Emergency Department for Nonemergent Complaints.

OBJECTIVE: The objective of this study was to explore the factors associated with parents' decisions to bring their children to the pediatric emergency department (PED) for nonemergent concerns. METHODS: We conducted a cross-sectional survey at a tertiary-care, pediatric referral center emergency department. We surveyed caregivers of children triaged to low-acuity levels using the Pediatric Canadian Triage and Acuity Scale. We used descriptive statistics to report the proportion of patients who have a primary care physician, who attempted to contact any health care providers prior to coming to the PED, and other factors surrounding the decision to come to the PED. RESULTS: We approached 340 families, of which 300 were enrolled (uptake rate, 88.2%). We found that 32% (95% confidence interval, 0.26-0.37) attempted to contact another health care provider prior to coming to the PED, and 59% (95% confidence interval, 0.48-0.69) of those respondents were specifically instructed to come to the PED. The top 3 reasons for coming to the British Columbia Children's Hospital PED were (1) that it specializes in children, (2) child has medical issues previously managed at the same hospital, and (3) closest location to patient. CONCLUSIONS: Despite the majority of patients having a primary care physician, less than half of them actually contacted these providers (or another health care provider) before presenting to the PED for their nonurgent illness or injury. Of these, nearly two thirds were specifically instructed to come to the PED by the health care provider in the community.

The impact of unstable housing on emergency department use in a cohort of HIV-positive people in a Canadian setting.

The social-structural challenges experienced by people living with HIV (PHA) have been shown to contribute to increased use of the emergency department (ED). This study identified factors associated with frequent and nonurgent ED use within a cohort of people accessing antiretroviral therapy (ART) in a Canadian setting. Interviewer-administered surveys collected socio-demographic information; clinical variables were obtained through linkages with the provincial drug treatment registry; and ED admission data were abstracted from the Department of Emergency Medicine database. Multivariate logistic regression was used to compute odds of frequent and nonurgent ED use. Unstable housing was independently associated with ED use (adjusted odds ratio [AOR] =1.94, 95% confidence interval [CI] 1.24-3.04]), having three or more ED visits within 6 months of the interview date [AOR: 2.03 (95% CI: 1.07-3.83)] and being triaged as nonurgent (AOR = 2.71, 95% CI: 1.19-6.17). Frequent and nonurgent use of the ED in this setting is associated with conditions requiring interventions at the social-structural level. Supportive housing may contribute to decreased health-care costs and improved health outcomes amongst marginalized PHA.

Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis.

STUDY OBJECTIVE: Allergic reactions are common presentations to the emergency department (ED). An unknown proportion of patients will develop biphasic reactions, and patients are often monitored for prolonged periods to manage potential reactions. We seek to determine the incidence of clinically important biphasic reactions. METHODS: Consecutive adult patients presenting to 2 urban EDs with allergic reactions during a 5-year period were identified. Encounters were dichotomized as "anaphylaxis" or "allergic reaction" with an explicit algorithm. A comprehensive chart review was conducted on each index and all subsequent visits to detail patient presentations, comorbidities, ED management, and predefined clinically important biphasic reactions. Regional and provincial databases were linked to identify subsequent ED visits and deaths within a 7-day period. The primary outcome was the proportion of patients with a clinically important biphasic reaction, and the secondary outcome was mortality. RESULTS: Of 428,634 ED visits, 2,819 (0.66%) encounters were reviewed (496 anaphylactic and 2,323 allergic reactions). Overall, 185 patients had at least 1 subsequent visit for allergic symptoms. Five clinically important biphasic reactions were identified (0.18%; 95% confidence interval [CI] 0.07% to 0.44%), with 2 occurring during the ED visit and 3 postdischarge. There were no fatalities (95% CI 0% to 0.17%). In the anaphylaxis and allergic reaction groups, clinically important biphasic reactions occurred in 2 patients (0.40%; 95% CI 0.07% to 1.6%) and 3 patients (0.13%; 95% CI 0.03% to 0.41%), respectively. CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, clinically important biphasic reactions and fatalities are rare. Our data suggest that prolonged routine monitoring of patients whose symptoms have resolved is likely unnecessary for patient safety.

Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter.

STUDY OBJECTIVE: Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days. RESULTS: Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated. CONCLUSION: In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.

Risk factors associated with 1-week revisit among emergency department patients with alcohol withdrawal.

BACKGROUND: Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1 week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits. RESULTS: We collected 935 ED visits among 593 unique patients. Median age was 45 years (interquartile range 34 to 55 years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30 days, no fixed address, initial blood alcohol level > 45 mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits. CONCLUSION: Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

RéSUMé: CONTEXTE: Environ un quart des visites aux urgences pour sevrage alcoolique se traduit par un retour non programmé aux urgences pendant une semaine, mais les facteurs cliniques et relatifs aux patients qui peuvent avoir une incidence sur ce résultat ne sont pas clairs. MéTHODES: Du 1er janvier 2015 au 31 décembre 2018, dans trois urgences urbaines de Vancouver, au Canada, nous avons étudié les patients qui sont sortis avec un diagnostic primaire ou secondaire de sevrage alcoolique. Nous avons procédé à une analyse structurée des dossiers afin de déterminer les caractéristiques des patients, les traitements aux urgences et l'issue d'un retour aux urgences dans la semaine suivant la sortie. Nous avons utilisé une régression binomiale bayésienne univariable et multivariable pour identifier les caractéristiques associées au fait d'être dans le quartile supérieur des visites aux urgences à une semaine. RéSULTATS: Nous avons recueilli 935 visites aux urgences parmi 593 patients uniques. L'âge médian était de 45 ans (intervalle interquartile de 34 à 55 ans) et 71 % étaient des hommes. Le risque d'une nouvelle visite aux urgences à une semaine était de 15,0% (IQR 12,3 ; 19,5%). Après ajustement, les facteurs indépendamment associés à un risque élevé de retour comprenaient toute visite antérieure à l'urgence dans les 30 jours, aucune adresse fixe, le taux d'alcoolémie initial > 45 mmol/L, et l'évaluation initiale du sevrage de l'Institut clinique ­ cote d'alcoolémie révisée > 23. Ces facteurs expliquaient 41 % de la variance globale des visites. CONCLUSIONS: Parmi les patients sortants des urgences en sevrage alcoolique, nous décrivons les caractéristiques des patients à haut risque associés à la réadmission aux urgences après une semaine de sevrage alcoolique. Ces résultats peuvent aider les cliniciens à planifier de manière appropriée la sortie de l'hôpital et à accéder à un suivi intégré.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain.

STUDY OBJECTIVE: Chest pain units have been used to monitor and investigate emergency department (ED) patients with potential ischemic chest pain to reduce the possibility of missed acute coronary syndrome. We seek to optimize the use of hospital resources by implementing a chest pain diagnostic algorithm. METHODS: This was a prospective cohort study of ED patients with potential ischemic chest pain. High-risk patients were referred to cardiology, and patients without ECG or biomarker evidence of ischemia were discharged home after 2 to 6 hours of observation. Emergency physicians scheduled discharged patients for outpatient stress ECGs or radionuclide scans at the hospital within 48 hours. Patients with positive provocative test results were immediately referred back to the ED. The primary outcome was the rate of missed diagnosis of acute coronary syndrome at 30 days. RESULTS: We prospectively followed 1,116 consecutive patients who went through the chest pain diagnostic algorithm, of whom 197 (17.7%) were admitted at the index visit and 254 (22.8%) received outpatient testing on discharge. The 30-day acute coronary syndrome event rate was 10.8%, and the 30-day missed acute coronary syndrome rate was 0% (95% confidence interval 0% to 2.4%). Of the 120 acute coronary syndrome cases, 99 (82.5%) were diagnosed at the index ED visit, and 21 patients (17.5%) received the diagnosis during outpatient stress testing. CONCLUSION: In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.