Psychostimulant drug co-ingestion in non-fatal opioid overdose.

Introduction: In 2019, there were over 16,000 deaths from psychostimulant overdose with 53.5% also involving an opioid. Given the substantial mortality stemming from opioid and psychostimulant co-exposure, evaluation of clinical management in this population is critical but remains understudied. This study aims to characterize and compare clinical management and outcomes in emergency department (ED) overdose patients with analytically confirmed exposure to both opioids and psychostimulants with those exposed to opioids alone. Methods: This was a secondary analysis of a prospective consecutive cohort of ED patients age 18+ with opioid overdose at 9 hospital sites from September 21, 2020 to August 17, 2021. Toxicologic analysis was performed using liquid chromatography quadrupole time-of-flight mass spectrometry. Patients were divided into opioid-only (OO) and opioid plus psychostimulants (OS) groups. The primary outcome was total naloxone bolus dose administered. Secondary outcomes included endotracheal intubation, cardiac arrest, troponin elevation, and abnormal presenting vital signs. We employed t-tests, chi-squared analyses and multivariable regression models to compare outcomes between OO and OS groups. Results: Of 378 enrollees with confirmed opioid overdose, 207 (54.8%) had psychostimulants present. OO patients were significantly older (mean 45.2 versus 40.6 years, p < 0.01). OS patients had significantly higher total naloxone requirements (mean total dose 2.79 mg versus 2.12 mg, p = 0.009). There were no significant differences in secondary outcomes. Conclusion: Approximately half of ED patients with confirmed opioid exposures were also positive for psychostimulants. Patients in the OS group required significantly higher naloxone doses, suggesting potential greater overdose severity.

Cocaethylene cardiotoxicity in emergency department patients with acute drug overdose.

OBJECTIVES: Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co-ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. METHODS: This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. RESULTS: We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p = 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p = 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p = 0.038). CONCLUSIONS: When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury.

Emergency Department Utilization Patterns in Patients with Opioid-Related Emergency Department Visits.

Opioid-related Emergency Department (ED) visits have surged over the past decade. There is limited data on ED utilization patterns of patients with opioid use disorder (OUD). An improved understanding of utilization may underscore missed opportunities for screening, intervention and referral.This was a retrospective 2:1 matched case-control study conducted at a single urban ED. Cases were patients with an opioid-related index ED visit from June 1, 2017 to May 31, 2018. Controls were patients with a non-opioid related index ED visit from June 1, 2018 to May 31, 2019. The primary outcome was the association between the number of ED visits in the 24-month period surrounding the index visit (12 months prior and 12 months following) and having an opioid-related index ED visit.There were a total of 224 cases. One or more visits preceding (OR: 1.63, 95% CI: 1.17, 2.26) and following the index visit (OR: 2.69, 95% CI: 1.91, 3.78) was significantly associated with case status. Following adjustment, a higher number of visits preceding (aOR: 1.24, 95% CI: 1.08, 1.43) and following the index visit (aOR: 1.39, 95% CI: 1.23, 1.57) remained significantly associated with case status.Patients with an opioid-related index ED visit had significantly higher rates of ED utilization 12 months before and after the index visit when compared to a matched control population. These findings suggest that there are significant opportunities for ED intervention and referral to treatment both prior to and following an opioid-related ED visit in this patient population.

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.

Delayed QT Prolongation: Derivation of a Novel Risk Factor for Adverse Cardiovascular Events from Acute Drug Overdose.

INTRODUCTION: In ED patients with acute drug overdose involving prescription medication and/or substances of abuse, severe QTc prolongation (> 500 ms) is predictive of adverse cardiovascular events (ACVE), defined as myocardial injury, ventricular dysrhythmia, shock, or cardiac arrest. However, it is unclear whether delayed severe QTc prolongation (dsQTp) is a risk factor for ACVE and if specific clinical factors are associated with occurrence of dsQTp. METHODS: A secondary analysis of a prospective cohort of consecutive adult ED patients with acute drug overdose was performed on patients with initial QTc < 500 ms. The predictor variable, dsQTp, was defined as initial QTc < 500 ms followed by repeat QTc ≥ 500 ms. The primary outcome was occurrence of ACVE. Multivariable logistic regression was performed to test whether dsQTp was an independent predictor of ACVE and to derive clinical factors associated with dsQTp. RESULTS: Of 2311 patients screened, 1648 patients were included. The dsQTp group (N = 27) was older than the control group (N = 1621) (51.6 vs 40.2, p < 0.001) and had a higher number of drug exposures (2.92 vs 2.16, p = 0.003). Following adjustment for age, sex, race/ethnicity, number of exposures, serum potassium, and opioid exposure, dsQTp remained an independent predictor of ACVE (aOR: 12.44, p < 0.0001). Clinical factors associated with dsQTp were age > 45 years and polydrug (≥ 3) overdoses. CONCLUSION: In this large secondary analysis of ED patients with acute drug overdose, dsQTp was an independent risk factor for in-hospital occurrence of ACVE.

Conceptualizing the effects of the COVID-19 pandemic on people with opioid use disorder: an application of the social ecological model.

The COVID-19 pandemic has resulted in unparalleled societal disruption with wide ranging effects on individual liberties, the economy, and physical and mental health. While no social strata or population has been spared, the pandemic has posed unique and poorly characterized challenges for individuals with opioid use disorder (OUD). Given the pandemic's broad effects, it is helpful to organize the risks posed to specific populations using theoretical models. These models can guide scientific inquiry, interventions, and public policy. Models also provide a visual image of the interplay of individual-, network-, community-, structural-, and pandemic-level factors that can lead to increased risks of infection and associated morbidity and mortality for individuals and populations. Such models are not unidirectional, in that actions of individuals, networks, communities and structural changes can also affect overall disease incidence and prevalence. In this commentary, we describe how the social ecological model (SEM) may be applied to describe the theoretical effects of the COVID-19 pandemic on individuals with opioid use disorder (OUD). This model can provide a necessary framework to systematically guide time-sensitive research and implementation of individual-, community-, and policy-level interventions to mitigate the impact of the COVID-19 pandemic on individuals with OUD.

Antidotal Sodium Bicarbonate Therapy: Delayed QTc Prolongation and Cardiovascular Events.

BACKGROUND: Sodium bicarbonate therapy (SBT) is currently indicated for the management of a variety of acute drug poisonings. However, SBT effects on serum potassium concentrations may lead to delayed QTc prolongation (DQTP), and subsequent risk of adverse cardiovascular events (ACVE), including death. Emergency department (ED)-based studies evaluating associations between SBT and ACVE are limited; thus, we aimed to investigate the association between antidotal SBT, ECG changes, and ACVE. METHODS: This was a secondary data analysis of a consecutive cohort of ED patients with acute drug overdose over 3 years. Demographic and clinical data as well as SBT bolus dosage and infusion duration were collected, and outcomes were compared with an unmatched consecutive cohort of patients with potential indications for SBT but who did not receive SBT. The primary outcome was the occurrence of ACVE, and secondary outcomes were delayed QTc (Bazett) prolongation (DQTP), and death. Propensity score and multivariable adjusted analyses were conducted to evaluate associations between adverse outcomes and SBT administration. Planned subgroup analysis was performed for salicylates, wide QRS (> 100 ms), and acidosis (pH < 7.2). RESULTS: Out of 2365 patients screened, 369 patients had potential indications for SBT, of whom 31 (8.4%) actually received SBT. In adjusted analyses, SBT was found to be a significant predictor of ACVE (aOR 9.35, CI 3.6-24.1), DQTP (aOR 126.7, CI 9.8-1646.2), and death (aOR 11.9, CI 2.4-58.9). Using a propensity score model, SBT administration was associated with ACVE (OR 5.07, CI 1.8-14.0). Associations between SBT and ACVE were maintained in subgroup analyses of specific indications for sodium channel blockade (OR 21.03, CI 7.16-61.77) and metabolic acidosis (OR: 6.42, 95% CI: 1.20, 34.19). CONCLUSION: In ED patients with acute drug overdose and potential indications for SBT, administration of SBT as part of routine clinical care was an independent, dose-dependent, predictor of ACVE, DQTP, and death. This study was not designed to determine whether the SBT or acute overdose itself was causative of ACVE; however, these data suggest that poisoned patients receiving antidotal SBT require close cardiovascular monitoring.

Pilot survey of prescription opioid use patterns and engagement with harm-reduction strategies in emergency department patients.

Background: The United States is experiencing an opioid epidemic. The aim of this pilot study was to describe patterns of prescription opioid medication (POM) use, examine factors associated with opioid misuse and overdose, and assess knowledge of take-home naloxone, and other harm-reduction strategies as well as participation in medications for opioid use disorder (MOUD) among emergency department (ED) patients that have been prescribed opioid medications. Methods: This was a pilot survey of a convenience sample of adult ED patients with a past opioid prescription at one urban tertiary care hospital. The survey asked participants about patterns of opioid consumption, risk factors associated with opioid misuse, and knowledge of harm-reduction strategies. The survey tool consisted of mixed open- and closed-ended questions. Reported daily POM consumption was converted to milligram morphine equivalents (MME). Responses to survey questions were compared with daily MME in order to generate hypotheses for future research. Results: 50 individuals completed a survey. Of these, 56% reported taking opioids daily, and 24% reported greater than 100 MME daily opioid consumption. Many subjects reported history of psychiatric illness (34%) and previous substance abuse treatment (24%). The majority of patients (66%) were not aware of take-home naloxone programs to treat opioid overdose. Conclusions: In this pilot survey of ED patients with a pain-related chief complaint, many respondents reported risk factors for opioid misuse, and the majority of participants were unaware of the existence of important harm-reduction strategies, such as take-home naloxone programs, even among those with the highest daily POM use.

Retrospective Cohort Study of Rates of Return Emergency Department Visits Among Patients Transported Home by Ambulance.

BACKGROUND: Emergency Medical Services (EMS) is an important resource that interacts with our most vulnerable patients during transport home after hospital discharge. EMS providers may be appropriately situated to support the transition of care to the home environment. OBJECTIVES: This study aimed to determine whether patients transported home by ambulance experience higher rates of return emergency department (ED) visits and readmission compared with similar patients transported home by other means. METHODS: This was a retrospective cohort study conducted at a U.S. tertiary care academic hospital. Patients aged 65 years and over transported home via ambulance after hospital discharge between January and March 2012 were included. Rates of 72-h and 30-day ED revisits and 30-day hospital readmissions were calculated. Odds ratios were calculated and revisit rates between groups were compared. RESULTS: There were 207 patients aged 65 and over transported home by ambulance. Matched controls were found for 162 patients. Compared with the matched controls, the exposed group experienced a statistically significant higher rate of 30-day ED returns (18.519% vs. 10.494%; odds ratio [OR] 1.939; p = 0.043). The exposed group also experienced a higher rate of 72-h ED returns (2.469% vs. 0.617%; OR 4.076) and 30-day readmissions (12.346% vs. 6.173%; OR 2.141), though results did not reach statistical significance. CONCLUSION: The study findings suggest that transport home via ambulance after hospital discharge could be predictive of a high risk of recidivism independent of established readmission risk factors. Programs that expand the role of EMS to include post-transport interventions may warrant further exploration.

Observation unit management of low-risk emergency department patients with acute drug overdose.

Introduction: Observation units (OU) are being increasingly used within the Emergency Department (ED) to optimize care and reduce costs, but their use for management of overdose patients is unclear. The present study examined demographics, disposition and outcomes for ED overdose patients managed in an OU.Methods: This was a secondary analysis of a prospective consecutive cohort of adult overdose patients managed in an OU in a single ED from March 2015 to September 2018. The primary composite study outcome was occurrence of any advanced airway intervention, adverse cardiovascular events (ACVE), or mortality. Secondary outcomes were disposition and return visits.Results: Of 946 patients screened, 648 were included in the cohort. Of 132 patients requiring additional medical management after the ED visit, 25 (18.9%) were managed in the OU; 88% of OU patients were discharged home, no patients required airway management, one patient experienced an ACVE requiring admission, and there were no deaths. Three OU patients (12%) had 30-day return visits.Conclusion: In this study, almost one-fifth of patients requiring additional medical management after the ED visit qualified for a low-risk drug overdose OU pathway. Overdoses from a variety of substances were safely managed with acceptably low adverse event rates.

Emergency Nursing Policy and Hypertension Awareness: an Integrative Review of the Literature.

PURPOSE OF REVIEW: This study aims to systematically examine the literature on nursing policy and hypertension (HTN) awareness in the emergency department (ED). RECENT FINDINGS: The electronic databases searched included Pubmed, OVID, CINAHL, and Web of Science. Studies were limited by adult, English language, and peer-reviewed articles published in the USA between the years 2015 and 2018. Our literature search allowed for quantitative and qualitative studies with a focus on nursing policy and adult patients treated in the ED who have HTN or elevated BP. Eight quantitative studies were retained for review and appraisal, and were rated to be of moderate quality evidence. Findings were summarized under three themes: BP reassessment, referral, and practice. The role of ED nurses in the screening and referral of this patient population remains largely uncharacterized. More robust trials are critically needed to improve practice and outcomes for patients with uncontrolled HTN. Clinical trials are needed to examine the efficacy of ED-based interventions on BP control, using multi-disciplinary samples of ED clinicians.

Screening emergency department patients for opioid drug use: A qualitative systematic review.

INTRODUCTION: The opioid drug epidemic is a major public health concern and an economic burden in the United States. The purpose of this systematic review is to assess the reliability and validity of screening instruments used in emergency medicine settings to detect opioid use in patients and to assess psychometric data for each screening instrument. METHODS: PubMed/MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov were searched for articles published up to May 2018. The extracted articles were independently screened for eligibility by two reviewers. We extracted 1555 articles for initial screening and 95 articles were assessed for full-text eligibility. Six articles were extracted from the full-text assessment. RESULTS: Six instruments were identified from the final article list: Screener and Opioid Assessment for Patients with Pain - Revised; Drug Abuse Screening Test; Opioid Risk Tool; Current Opioid Misuse Measure; an Emergency Medicine Providers Clinician Assessment Questionnaire; and an Emergency Provider Impression Data Collection Form. Screening instrument characteristics, and reliability and validity data were extracted from the six studies. A meta-analysis was not conducted due to heterogeneity between the studies. CONCLUSIONS: There is a lack of validity and reliability evidence in all six articles; and sensitivity, specificity and predictive values varied between the different instruments. These instruments cannot be validated for use in emergency medicine settings. There is no clear evidence to state which screening instruments are appropriate for use in detecting opioid use disorders in emergency medicine patients. There is a need for brief, reliable, valid and feasible opioid use screening instruments in the emergency medicine setting.

Hepatitis A Virus: Essential Knowledge and a Novel Identify-Isolate-Inform Tool for Frontline Healthcare Providers.

Infection with hepatitis A virus (HAV) causes a highly contagious illness that can lead to serious morbidity and occasional mortality. Although the overall incidence of HAV has been declining since the introduction of the HAV vaccine, there have been an increasing number of outbreaks within the United States and elsewhere between 2016 and 2017. These outbreaks have had far-reaching consequences, with a large number of patients requiring hospitalization and several deaths. Accordingly, HAV is proving to present a renewed public health challenge. Through use of the "Identify-Isolate-Inform" tool as adapted for HAV, emergency physicians can become more familiar with the identification and management of patients presenting to the emergency department (ED) with exposure, infection, or risk of contracting disease. While it can be asymptomatic, HAV typically presents with a prodrome of fever, nausea/vomiting, and abdominal pain followed by jaundice. Healthcare providers should maintain strict standard precautions for all patients suspected of having HAV infection as well as contact precautions in special cases. Hand hygiene with soap and warm water should be emphasized, and affected patients should be counseled to avoid food preparation and close contact with vulnerable populations. Additionally, ED providers should offer post-exposure prophylaxis to exposed contacts and encourage vaccination as well as other preventive measures for at-risk individuals. ED personnel should inform local public health departments of any suspected case.

Use of Physician-in-Triage Model in the Management of Abdominal Pain in an Emergency Department Observation Unit.

INTRODUCTION: Given the nationwide increase in emergency department (ED) visits it is of paramount importance for hospitals to find efficient ways to manage patient flow. The purpose of this study was to determine whether there is a significant difference in success rates, length of stay (LOS), and other demographic factors in two cohorts of patients admitted directly to an ED observation unit (EDOU) under an abdominal pain protocol by a physician in triage (bypassing the main ED) versus those admitted via the traditional pathway (evaluated and treated in the main ED prior to EDOU admission). METHODS: This was a retrospective cohort study of patients admitted to a protocol-driven EDOU with a diagnosis of abdominal pain in a single university hospital center ED. We obtained compiled data for all patients admitted to the EDOU with a diagnosis of abdominal pain that met EDOU protocol admission criteria. We divided data for each cohort into age, gender, payer status, and LOS. The data were then analyzed to assess any significant differences between the cohorts. RESULTS: A total of 327 patients were eligible for this study (85 triage group, 242 main ED group). The total success rate was 90.8% (n=297) and failure rate was 9.2% (n=30). We observed no significant differences in success rates between those dispositioned to the EDOU by triage physicians (90.6%) and those via the traditional route (90.5 % p) = 0.98. However, we found a significant difference between the two groups regarding total LOS with significantly shorter main ED times and EDOU times among patients sent to the EDOU by the physician-in-triage group (p< .001). CONCLUSION: There were no significant differences in EDOU disposition outcomes in patients admitted to an EDOU by a physician-in-triage or via the traditional route. However, there were statistically significant shorter LOSs in patients admitted to the EDOU by triage physicians. The data from this study support the implementation of a physician-in-triage model in combination with the EDOU in improving efficiency in the treatment of abdominal pain. This knowledge may spur action to cut healthcare costs and improve patient flow and timely decision-making in hospitals with EDOUs.

Mumps Virus: Modification of the Identify-Isolate-Inform Tool for Frontline Healthcare Providers.

Mumps is a highly contagious viral infection that became rare in most industrialized countries following the introduction of measles-mumps-rubella (MMR) vaccine in 1967. The disease, however, has been re-emerging with several outbreaks over the past decade. Many clinicians have never seen a case of mumps. To assist frontline healthcare providers with detecting potential cases and initiating critical actions, investigators modified the "Identify-Isolate-Inform" tool for mumps infection. The tool is applicable to regions with rare incidences or local outbreaks, especially seen in college students, as well as globally in areas where vaccination is less common. Mumps begins with a prodrome of low-grade fever, myalgias and malaise/anorexia, followed by development of nonsuppurative parotitis, which is the pathognomonic finding associated with acute mumps infection. Orchitis and meningitis are the two most common serious complications, with hearing loss and infertility occurring rarely. Providers should consider mumps in patients with exposure to a known case or international travel to endemic regions who present with consistent signs and symptoms. If mumps is suspected, healthcare providers must immediately implement standard and droplet precautions and notify the local health department and hospital infection control personnel.

Zika Virus: Critical Information for Emergency Providers.

Zika virus is an arbovirus of the Flaviviridae family. It is primarily a minimally symptomatic mosquito-borne infection. However, with Zika's 2015 to 2016 introduction into the Western Hemisphere and its dramatic and rapid spread, it has become a public health concern, in large part due to congenital abnormalities associated with infection in pregnant women. In early 2016, the World Health Organization declared the microcephaly and other neurologic conditions associated with Zika virus infection a public health emergency of international concern. This article discusses the current epidemiologic and clinical understanding of Zika virus, focusing on critical information needed by emergency providers.

Patient Perspectives on EMS Alternate Destination Models.

INTRODUCTION: Studies have shown that a large number of ambulance transports to emergency departments (ED) could have been safely treated in an alternative environment, prompting interest in the development of more patient-centered models for prehospital care. We examined patient attitudes, perspectives, and agreement/comfort with alternate destinations and other proposed innovations in Emergency Medical Services (EMS) care delivery and determined whether demographic, socioeconomic, acuity, and EMS utilization history factors impact levels of agreement. METHODS: We conducted a cross-sectional study on a convenience sample of patients and caregivers presenting to an urban academic ED between July 2012 and May 2013. Respondents were surveyed on levels of agreement with 13 statements corresponding to various aspects of a proposed patient-centered emergency response system including increased EMS access to healthcare records, shared decision making with the patient and/or primary care physician, transport to alternative destinations, and relative importance of EMS assessment versus transportation. Information on demographic and socioeconomic factors, level of acuity, and EMS utilization history were also determined via survey and chart review. Responses were analyzed descriptively and compared across patient characteristics using chi-square and regression analyses. RESULTS: A total of 621 patients were enrolled. The percentage of patients who agreed or strongly agreed with each of the 13 statements ranged from 48.2 to 93.8%. About 86% agreed with increased EMS access to healthcare records; approximately 72% agreed with coordinating disposition decisions with a primary physician; and about 58% supported transport to alternative destinations for low acuity conditions. No association was found between levels of agreement and the patient's level of acuity or EMS utilization history. Only Black or Hispanic race showed isolated associations with lower rates of agreement with some aspects of an innovative EMS care delivery model. CONCLUSION: A substantial proportion of patients surveyed in this cross sectional study agreed with a more patient-centered approach to prehospital care where a 9-1-1 call could be met with a variety of treatment and transportation options. Agreement was relatively consistent among a diverse group of patients with varying demographics, levels of acuity and EMS utilization history. MeSH Key words: emergency medical services; triage; telemedicine; surveys and questionnaires; transportation of patients.