Implementation and Evaluation of an Automated Text Message-Based Diabetes Prevention Program for Adults With Pre-diabetes.

BACKGROUND: Despite the efficacy of diabetes prevention programs, only an estimated 5% of people with pre-diabetes actually participate. Mobile health (mHealth) holds promise to engage patients with pre-diabetes into lifestyle modification programs by decreasing the referral burden, centralizing remote enrollment, removing the physical requirement of a brick-and-mortar location, lowering operating costs through automation, and reducing time and transportation barriers. METHODS: Non-randomized implementation study enrolling patients with pre-diabetes from a large health care organization. Patients were exposed to a text message-based program combining live human coaching guidance and support with automated scheduled, interactive, data-driven, and on-demand messages. The primary analysis examined predicted weight outcomes at 6 and 12 months. Secondary outcomes included predicted changes in HbA1c and minutes of exercise at 6 and 12 months. RESULTS: Of the 163 participants included in the primary analysis, participants had a mean predicted weight loss of 5.5% at six months (P < .001) and of 4.3% at 12 months (P < .001). We observed a decrease in predicted HbA1c from 6.1 at baseline to 5.8 at 6 and 12 months (P < .001). Activity minutes were statistically similar from a baseline of 155.5 minutes to 146.0 minutes (P = .567) and 142.1 minutes (P = .522) at 6 and 12 months, respectively, for the overall cohort. CONCLUSIONS: In this real-world implementation of the myAgileLife Diabetes Prevention Program among patients with pre-diabetes, we observed significant decreases in weight and HbA1c at 6 and 12 months. mHealth may represent an effective and easily scalable potential solution to deliver impactful diabetes prevention curricula to large numbers of patients.

Effect of Prescriber Notifications of Patient's Fatal Overdose on Opioid Prescribing at 4 to 12 Months: A Randomized Clinical Trial.

This randomized clinical trial evaluates the effect of prescriber notifications of a patient's fatal overdose on opioid prescribing, including decreases in morphine milligram equivalents, new patients taking opioids, and patients taking a high dose, at 4 to 12 months after notification.

Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged From the Emergency Department With Supplemental Oxygen.

STUDY OBJECTIVE: To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. METHODS: This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. RESULTS: Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). CONCLUSION: COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.

Assessing the Use of Data Systems to Estimate Return-on-Investment of Behavioral Healthcare Interventions: Opportunities and Barriers.

To improve access to and quality of affordable behavioral healthcare, there is a need for more research to identify which interventions can generate long-term, societal return-on-investment (ROI). Barriers to ROI studies in the behavioral health sector were explored by conducting semi-structured interviews with individuals from key stakeholder groups at state and national behavioral health-related organizations. Limited operating budgets, state-based payer systems, the lack of financial support, privacy laws, and other unique experiences of behavioral health providers and patients were identified as important factors that affect the collection and utilization of data. To comprehensively assess ROI of interventions, it is necessary to improve standardization and data infrastructure across multiple health and non-health systems and clarify or address legal, regulatory, and commercial conflicts.

Association of Fatal Overdose Notification Letters With Prescription of Benzodiazepines: Secondary Analysis of a Randomized Clinical Trial.

This secondary analysis of a randomized clinical trial examines the association of receipt of an injunction letter from a medical examiner following a patient's drug overdose with patterns of benzodiazepine prescribing among physicians.

Technological Proficiencies, Engagement, and Practical Considerations for mHealth Programs at an Urban Safety-Net Hospital Emergency Departments: Data Analysis.

BACKGROUND: Safety-net emergency departments often serve as the primary entry point for medical care for low income predominantly minority patient populations. Herein, we sought to provide insight into the feasibility, technological proficiencies, engagement characteristics, and practical considerations for a mHealth intervention at a safety-net emergency department. OBJECTIVE: We aimed to analyze patient technological proficiency to understand the feasibility of and draw practical considerations for mobile phone technology (mHealth) solutions for patients with chronic disease served by safety-net emergency departments. METHODS: We analyzed data from a previous diabetes randomized clinical mHealth trial for a diabetes social support intervention. Patients from a safety-net emergency department with preexisting diabetes who used SMS text messages, owned a mobile phone, and with hemoglobin A1c levels >8.5% were enrolled. A text message-based mHealth program to improve disease self-management was provided to all patients. Supporters of patients were randomized to receive a mailed copy or mHealth-based curriculum designed to improve diabetes support. Among enrolled patients, we surveyed mobile technological capacity and frequency of use. We performed latent class analysis to identify classes of patients by level of technological proficiency and compared demographic characteristics between the latent classes to identify demographic subgroups that may require more training or tailoring of the mHealth approach. Study engagement between classes was assessed by comparing the mean number of text messages exchanged, loss to follow-up, and early termination. RESULTS: Of 1876 patients who were approached, 44.2% (n=829) of patients had a stable mobile phone and were able to use text messages. Among them 166 met the trial inclusion and enrolled, 90% (149/166) of the cohort were ethnically diverse. Significant variance was found in technology capacity and frequency of use. Our latent class analysis classified 75% (124/166) of patients as highly technologically proficient and 25% (42/166) patients as minimally technologically proficient. Age (P<.001) and level of education (P<.001) were associated with class membership. Highly technologically proficient patients were younger and had higher levels of education (45.74 years old; high school or more: 90%) than minimally technologically proficient patients (53.64 years old; high school or more: 18%). Highly technologically proficient participants exchanged a mean of 40 text messages with the system coordinators compared to a mean of 10 text messages by minimally technologically proficient patients (P<.001). CONCLUSIONS: This study found that nearly half of the patients screened at the safety-net emergency department were equipped for an SMS text message-based mHealth intervention. In the small sample of patients who were enrolled, the majority were classified as highly technologically proficient. These highly proficient patients had greater study engagement. mHealth use in emergency departments may be an opportunity to improve health of ethnically diverse populations by pairing sophisticated chronic disease self-management program with SMS text message-based and traditional in-person interventions to reach patients through the method that is most familiar and comfortable. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1016/j.cct.2019.03.003.

Assessment of Implicit Gender Bias During Evaluation of Procedural Competency Among Emergency Medicine Residents.

Importance: Gender disparities exist throughout medicine. Recent studies have highlighted an attainment gap between male and female residents in performance evaluations on Accreditation Council for Graduate Medical Education (ACGME) milestones. Because of difficulties in blinding evaluators to gender, it remains unclear whether these observed disparities are because of implicit bias or other causes. Objective: To estimate the magnitude of implicit gender bias in assessments of procedural competency in emergency medicine residents and whether the gender of the evaluator is associated with identified implicit gender bias. Design, Setting, and Participants: A cross-sectional study was performed from 2018 to 2020 in which emergency medicine residency faculty assessed procedural competency by evaluating videos of residents performing 3 procedures in a simulated environment. They were blinded to the intent of the study. Proceduralists were filmed performing each procedure from 2 different viewpoints simultaneously by 2 different cameras. One was a gender-blinded (ie, hands-only) view, and the other a wide-angled gender-evident (ie, whole-body) view. The faculty evaluators viewed videos in a random order and assessed procedural competency on a global rating scale with extensive validity evidence for the evaluation of video-recorded procedural performance. Main Outcomes and Measures: The primary outcome was to determine if there was a difference in the evaluation of procedural competency based on gender. The secondary outcome was to determine if there was a difference in the evaluations based on the gender of the evaluator. Results: Fifty-one faculty evaluators enrolled from 19 states, with 22 male participants (43.1%), 29 female participants (56.9%), and a mean (SD) age of 37 (6.4) years. Each evaluator assessed all 60 procedures: 30 gender-blinded (hands-only view) videos and 30 identical gender-evident (wide angle) videos. There were no statistically significant differences in the study evaluators' scores of the proceduralists based on their gender, and the gender of the evaluator was not associated with the difference in mean scores. Conclusions and Relevance: In this study, we did not identify a difference in the evaluation of procedural competency based upon the gender of the resident proceduralist or the gender of the faculty evaluator.

Trauma Computed Tomography in the Modern Era: Not Always Quick and Safe.

BACKGROUND: Computed tomography (CT) has emerged as the diagnostic modality of choice in trauma patients. Recent studies suggest its use in hemodynamically unstable patients is safe and potentially lifesaving; however, the incidence of adverse events (AE) during the trauma CT scanning process remains unknown. STUDY DESIGN: Over a 6-month period at a Level 1 trauma center, data on patients undergoing trauma CT (whole-body CT (WBCT) +/- additional CT studies) were prospectively collected. All patients requiring a trauma team activation (TTA) were included. Adverse events and specific time intervals were recorded from the time of TTA notification to the time of return to the resuscitation bay from the CT suite. RESULTS: Of the 94 consecutive patients included in the study, 47.9% experienced 1 or more AE. Median duration away from the resuscitation bay for all patients was 24 minutes. Patients with AE spent a significantly longer time away from the resuscitation bay and had longer scan times. Vasopressor support and ongoing transfusion requirement at the time of CT scanning were associated with AE. CONCLUSION: Adverse events of varying clinical significance occur frequently in patients undergoing emergent trauma CT. A standard trauma CT protocol could improve the efficiency and safety of the scanning process.

Who Stayed Home Under Safer-at-Home? Impacts of COVID-19 on Volume and Patient-Mix at an Emergency Department.

INTRODUCTION: To describe the impact of COVID-19 on a large, urban emergency department (ED) in Los Angeles, California, we sought to estimate the effect of the novel coronavirus 2019 (COVID-19) and "safer-at-home" declaration on ED visits, patient demographics, and diagnosis-mix compared to prior years. METHODS: We used descriptive statistics to compare ED volume and rates of admission for patients presenting to the ED between January and early May of 2018, 2019, and 2020. RESULTS: Immediately after California's "safer-at-home" declaration, ED utilization dropped by 11,000 visits (37%) compared to the same nine weeks in prior years. The drop affected patients regardless of acuity, demographics, or diagnosis. Reductions were observed in the number of patients reporting symptoms often associated with COVID-19 and all other complaints. After the declaration, higher acuity, older, male, Black, uninsured or non-Medicaid, publicly insured, accounted for a disproportionate share of utilization. CONCLUSION: We show an abrupt, discontinuous impact of COVID-19 on ED utilization with a slow return as safer-at-home orders have lifted. It is imperative to determine how this reduction will impact patient outcomes, disease control, and the health of the community in the medium and long terms.

Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department.

BACKGROUND: Sepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance. OBJECTIVE: To evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients. METHODS: We performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups. RESULTS: Of the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = -0.406; 95% CI = -0.809, -0.003; p = 0.048) and time of triage to physician (coeff = -0.543; 95% CI = -0.864, -0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups. CONCLUSION: EMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.

Association Between Race/Ethnicity and Disparities in Health Care Use Before First-Episode Psychosis Among Privately Insured Young Patients.

Importance: Racial/ethnic disparities in health care use and clinical outcomes for behavioral health disorders, including psychosis, are well documented, but less is known about these disparities during the period leading up to first-episode psychosis (FEP). Objective: To describe the racial/ethnic disparities in behavioral health care use and prescription drug use of children and young adults before the diagnosis of FEP. Design, Setting, and Participants: An observational cohort study was conducted using medical and prescription drug claims from January 1, 2007, to September 30, 2015, obtained from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database augmented with race/ethnicity and socioeconomic variables. Data analysis was performed from February 6, 2018, to October 10, 2020. First-episode psychosis was determined by the presence of psychosis diagnoses on claims for at least 1 hospitalization or 2 outpatient events, with a continuous enrollment requirement of at least 2 years before the first diagnosis. Participants included 3017 Black, Hispanic, or White patients who were continually enrolled in commercial insurance plans and received an FEP diagnosis between the ages of 10 and 21 years. Main Outcomes and Measures: Race/ethnicity was determined from a commercial claims database. Rates of inpatient admission, emergency department presentation, and outpatient visits (including psychotherapy), behavioral health disorder diagnoses, and antipsychotic/antidepressant prescription fills were determined for the year before FEP. Race/ethnicity was also obtained from Optum's claims database. With use of multivariable logistic regression, results were adjusted for covariates including estimated household income, age, sex, and geographic division in the US. Results: Of the 3017 patients with FEP, 643 Black or Hispanic patients (343 [53.3%] Black, 300 [46.7%] Hispanic, 324 [50.4%] male, mean [SD] age, 17.2 [2.76] years) were less likely than 2374 White patients (1210 [51.0%] male, mean age, 17.0 [2.72] years) to receive comorbid behavioral health disorder diagnoses in the year before the diagnosis of FEP (410 [63.8%] vs 1806 [76.1%], χ2 = 39.3; P < .001). Except for emergency care, behavioral health care use rates were lower in Black and Hispanic patients vs White patients (424 [65.9%] vs 1868 [78.7%]; χ2 = 45.0; P < .001), particularly for outpatient visits with behavioral health care professionals (232 [36.1%] vs 1236 [52.1%]; χ2 = 51.7; P < .001). After adjustment for socioeconomic covariates, behavioral health care use rates (68.9% vs 79.2%; P < .001), outpatient visits with behavioral health professionals (37.7% vs 51.2%; P < .001), and other outcomes remained significantly lower for Black and Hispanic patients vs White patients. Conclusions and Relevance: The results of this study extend existing research findings of well-known racial/ethnic disparities in the population of patients who are diagnosed with FEP. These differences were apparent in young patients with continuous commercial health insurance and after controlling for household income. Providing equal access to preventive outpatient behavioral health care may increase opportunities for timely detection of psychotic symptoms and early intervention and improve differential outcomes after FEP.

The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events.

OBJECTIVES: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation. MATERIALS AND METHODS: A retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year. RESULTS: Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals. CONCLUSIONS: For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.

Feasibility and Acceptability of a Text Message-Based Intervention to Reduce Overuse of Alcohol in Emergency Department Patients: Controlled Proof-of-Concept Trial.

BACKGROUND: Emergency department (ED) patients have high rates of risky alcohol use, and an ED visit offers an opportunity to intervene. ED-based screening, brief intervention, and referral to treatment (SBIRT) reduces alcohol use and health care costs. Mobile health (mHealth) interventions may expand the impact of SBIRTs but are understudied in low-resource ED populations. OBJECTIVE: The objective of this study was to assess the feasibility of and patient satisfaction with a text-based mHealth extension of an ED screening program to reduce risky alcohol use in low-income, urban patients. METHODS: Research assistants screened a convenience sample of ED patients in person for risky alcohol use via the Alcohol Use Disorders Identification Test (AUDIT). Patients who reported AUDIT scores ≥8 and <20 were informed of their AUDIT score and risk. RAs invited patients with SMS text message-capable phones to receive mROAD (mobilizing to Reduce Overuse of Alcohol in the ED), an SMS text message-based extension of the ED screening program. mROAD is a 7-day program of twice-daily SMS text messages based on the National Institutes of Health's Rethinking Drinking campaign. Participants were allocated to a control group (daily sham text messages without specific guidance on behaviors, such as "Thanks for taking part!") or to the mROAD intervention group. Patients were interviewed at 30 days to assess acceptability, satisfaction, and changes in drinking behavior. Satisfaction was examined descriptively. Pre and post measurements of drinking behaviors and motivation were compared, as were differences in change scores between the intervention arms. RESULTS: Of 1028 patients screened, 95 (9.2%) exhibited risky alcohol use based on AUDIT, and 23/95 (24%) of those patients did not own an SMS text messaging-capable phone; this left 72/95 (76%) eligible patients. Among eligible participants, 48/72 (67%) agreed to enroll; 31/48 (65%) achieved follow-up (18/24 (75%) in the intervention group and 13/24 (55%) in the control group). Participants who completed follow-up reported high satisfaction. Changes in behavior were similar between the arms. Overall, the number of drinking days reported in the prior 30 days decreased by 5.0 (95% CI 1.7-8.3; P=.004), and the number of heavy drinking days decreased by 4.1 (95% CI 1.0 to 7.15, P=.01). Patients reported an 11-point increase (95% CI 2.6-20, P=.01, 10% overall increase) in motivation to change alcohol use via the Change Questionnaire. The were no statistical differences in drinking days, heavy drinking days, or motivation to change between the arms. CONCLUSIONS: The mROAD trial was feasible. Over three-quarters of ED patients with risky alcohol use owned a text message-capable phone, and two-thirds of these patients were willing to participate; only 1 patient opted out of the intervention. Although 35% of patients were lost to follow-up at 30 days, those patients who did follow up had favorable impressions of the program; more than 90% reported that SMS text messages were a "good way to teach," and 89% of intervention arm participants enjoyed the program and found that the messages were motivating. Both the mROAD and sham message groups showed promising changes in alcohol use and motivation to change. mROAD is a feasible intervention that may reduce rates of risky alcohol use in ED patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02158949; https://clinicaltrials.gov/ct2/show/NCT02158949.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies.

INTRODUCTION: The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition - labor - specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care. METHODS: We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements. RESULTS: Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle. CONCLUSION: Despite inclusion of the term "labor" in the law's title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

National trends in mental health-related emergency department visits by children and adults, 2009-2015.

OBJECTIVES: Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. METHODS: Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. RESULTS: Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. CONCLUSIONS: Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Adolescents' Willingness to Commit to Safe Use and Disposal of Prescription Opioids.

Introduction and aims: Leftover pills from prescriptions written in emergency departments are a key source of misused opioids among adolescents. Recently, the AMA has proposed emphasizing safe use and disposal of opioids, but patient perceptions on this proposed solution are largely unknown. In this study, we evaluate the willingness of adolescents to commit to pill security and safe opioid use in a clinical setting. Design and methods: In this prospective survey study conducted in an urban emergency department, a consecutive sample of adolescent patients between 15 and 22 years were asked about their exposure to opioids and attitudes toward the potential harm of opioid use/misuse and whether they were willing to consider to committing to pill security and safe opioid use in a clinical setting. We then assessed if willingness to commit varied based on attitude toward opioid misuse or previous experience with prescription opioids. Results: Eighty-one percent (91/113) of eligible patients agreed to participate. Overall 29.7% of adolescents had received a prescription for opioids and 40.7% had leftover pills. 87.9% were willing to commit to take opioids only as prescribed and 83.5% were willing to commit to disposing leftover opioids. Willingness did not vary by previous exposure to prescription opioids or attitudes toward recreational opioid use. Discussion and conclusions: Adolescents are highly willing to commit to safe opioid use and disposal regardless of previous exposure to opioids or attitude toward opioid misuse.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

BACKGROUND: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. METHODS: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. RESULTS: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001). CONCLUSIONS: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Opioid prescribing patterns in emergency departments and future opioid use in adolescent patients.

OBJECTIVE: Evidence suggests that exposure to opioids in adolescence increases risk of future opioid use. We evaluate if exposure to high versus low intensity opioid prescribers in the Emergency Department (ED) influences the risk of future opioid use in adolescents. METHODS: Retrospective study of opioid-naïve patients 10 to 17 years seen in one of 14 EDs between January 2013 and December 2014. We categorized ED providers into quartiles according to the proportion of encounters resulting in opioid prescriptions. Primary outcome was use of opioids in the subsequent 12 months. Analysis adjusted for patient characteristics and compared future use of opioids for patients seen by the lowest versus the highest prescribing quartiles. RESULTS: We included 9,688 patient encounters evaluated by the lowest opioid prescribing physician quartile versus 9,467 in the highest. The highest quartile gave opioid prescriptions to 14.9% of their patients compared to 2.8% for the lowest quartile. No association with future opioid use was found for patients evaluated by low versus high prescriber quartiles (OR 0.99, 95% CI 0.90-1.08). Patients with increasing age (OR 2.15, 95% CI 1.92-2.42) and white versus Hispanic ethnicity (OR 1.55, 95% CI 1.33-1.80) were associated with recurrent opioid use. CONCLUSION: We found no association between high intensity opioid prescribers and recurrent 12 month use of opioids in opioid-naïve adolescents seen in the ED. This likely reflects various factors that put adolescents at risk for recurrent opioid use and may indicate the importance of the second prescription from primary care after initial exposure to opioids.

Organizational factors associated with practitioners' support for treatment of opioid use disorder in the emergency department.

BACKGROUND: Despite the significant increase in emergency room visits for opioid overdose, only few emergency departments (ED) have implemented best practices to treat people with opioid use disorders (OUD). Some implementation gaps may be due to practitioner factors; such as support for medication-assisted treatment (MAT) for OUD in the ED. In this study, we explore the relationship between inner setting characteristics of the EDs (e.g., leadership, readiness for change, organizational climate) and practitioner support for OUD treatment and attitudes towards people with OUD. METHODS: We surveyed 241 ED practitioners (e.g., physicians, nurses, social workers) at one of the largest EDs in the United States. We used analysis of variance and chi-square global tests to compare responses from ED practitioners in differing roles. We also conducted five multivariate logistic regressions to explore associations between ED inner setting characteristics and five antecedents of implementation; ED practitioner (1) supports MAT for OUD in the ED, (2) supports best practices to treat OUD, (3) has self-efficacy to treat OUD, (4) has stereotypes of people who use drugs, and (5) has optimism to treat people with OUD. RESULTS: We found nurses were more likely than physicians to support MAT for OUD in the ED and delivering other best practices to treat OUD. At the same time, nurses had greater bias than physicians against working with patients suffering from OUD. We also found the ED's climate for innovation and practitioners' readiness for change were positively associated with support for MAT for OUD in the ED and using best practices to treat OUD. CONCLUSIONS: Findings suggest that professional roles and some ED inner setting factors play an important role in antecedents of implementation of OUD treatment in the ED. To prepare EDs to effectively respond to the current opioid overdose epidemic, it is critical to further understand the impact of these organizational factors on the implementation of evidence-based OUD treatment practices in the nation.

Prescription Opioid Use in General and Pediatric Emergency Departments.

BACKGROUND AND OBJECTIVES: Recent evidence reveals that exposure to emergency department (ED) opioids is associated with a higher risk of misuse. Pediatric EDs are generally thought to provide the highest-quality care for young persons, but most children are treated in general EDs. We sought to determine if ED opioid administration and prescribing vary between pediatric and general EDs. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (2006-2015), a representative survey of ED visits, by using multivariate logistic regressions. Outcomes of interest were the proportion of patients ≤25 years of age who (1) were administered an opioid in the ED, (2) were given a prescription for an opioid, or (3) were given a prescription for a nonopioid analgesic. The key predictor variable was ED type. A secondary analysis was conducted on the subpopulation of patients with a diagnosis of fracture or dislocation. RESULTS: Of patients ≤25 years of age, 91.1% were treated in general EDs. The odds of being administered an opioid in the ED were similar in pediatric versus general EDs (adjusted odds ratio [OR] 0.88; 95% confidence interval [CI] 0.61-1.27; P = .49). Patients seen in pediatric EDs were less likely to receive an outpatient prescription for opioids (adjusted OR 0.38; 95% CI 0.27-0.52; P < .01) than similar patients in general EDs. This was true for the fracture subset as well (adjusted OR 0.27; 95% CI 0.13-0.54; P < .01). CONCLUSIONS: Although children, adolescents, and young adults had similar odds of being administered opioids while in the ED, they were much less likely to receive an opioid prescription from a pediatric ED compared with a general ED.