Impact of drone-specific dispatch instructions on the safety and efficacy of drone-delivered emergency medical treatments: A randomized simulation pilot study.

Introduction: Medical drones have potential for improving the response times to out-of-hospital emergencies. However, widespread adoption is hindered by unanswered questions surrounding medical dispatch and bystander safety. This study evaluated the impact of novel drone-specific dispatch instructions (DSDI) on bystanders' ability to interact effectively with a medical drone and provide prompt, safe, and high-quality treatment in a simulated emergency scenario. We hypothesized DSDI would improve bystanders' performance and facilitate safer bystander-drone interactions. Methods: Twenty-four volunteers were randomized to receive either DSDI and standard Medical Priority Dispatch (MPD) instructions or MPD alone in a simulated out-of-hospital cardiac arrest (OHCA) or pediatric anaphylaxis.,3 Participants in the DSDI group received detailed instructions on locating and interacting with the drone and its enclosed medical kit. The simulations were video recorded. Participants completed a semi-structured interview and survey. Results: The addition of DSDI did not lead to statistically significant changes to the overall time to provide care in either the anaphylaxis or OHCA simulations. However, DSDI did have an impact on bystander safety. In the MPD only group, 50% (6/12) of participants ignored the audio and visual safety cues from the drone instead of waiting for it to be declared safe compared to no DSDI participants ignoring these safety cues. Conclusions: All participants successfully provided patient care. However, this study indicates that DSDI may be useful to ensure bystander safety and should be incorporated in the continued development of emergency medical drones.

Bystander interaction with a novel multipurpose medical drone: A simulation trial.

Intro: Medical drones are an emerging technology which may facilitate rapid treatment in time-sensitive emergencies. However, drones rely on lay rescuers, whose interactions with multipurpose medical drones have not been studied, and the optimal drone design remains unclear. Methods: We conducted 24 simulations of adult out-of-hospital cardiac arrest (OHCA) and pediatric anaphylaxis with a prototype drone equipped with spoken and visual cues and a multipurpose medical kit. 24 layperson volunteers encountered one of the two scenarios and were supported through administering treatment by a simulated 911 dispatcher. Bystander-drone interactions were evaluated via a convergent parallel mixed methods approach using surveys, video event review, and semi-structured interviews. Results: 83% (20/24) of participants voiced comfort interacting with the drone. 96% (23/24) were interested in future interaction. Participants appreciated the drone's spoken instructions but found visual cues confusing. Participants retrieved the medical kit from the drone in a mean of 5 seconds (range 2-14) of drone contact; 79% (19/24) found this step easy or very easy. The medical kit's layered design caused difficulty in retrieving appropriate equipment. Participants expressed a wide range of reactions to the unique drone design. Conclusions: Laypeople can effectively and comfortably interact with a medical drone with a novel design. Feedback on design elements will result in further refinements and valuable insights for other drone designers. A multipurpose medical kit created more challenges and indicates the need for further refinement to facilitate use of the equipment.

Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department.

BACKGROUND: Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention. OBJECTIVE: We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes. METHODS: We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity. RESULTS: Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery. CONCLUSION: Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation.

Alcohol Use and Mortality Among Older Couples in the United States: Evidence of Individual and Partner Effects.

BACKGROUND AND OBJECTIVES: Spouses with concordant (i.e., similar) drinking behaviors often report better quality marriages and are married longer compared with those who report discordant drinking behaviors. Less is known regarding whether concordant or discordant patterns have implications for health, as couples grow older. The present study examined whether drinking patterns among older couples are associated with mortality over time. RESEARCH DESIGN AND METHODS: The Health and Retirement Study (HRS) is a nationally representative sample of individuals and their partners (married/cohabiting) over age 50 in the United States, in which participants completed surveys every 2 years. Participants included 4,656 married/cohabiting different-sex couples (9,312 individuals) who completed at least 3 waves of the HRS from 1996 to 2016. Participants reported whether they drank alcohol at all in the last 3 months, and if so, the average amount they drank per week. Mortality data were from 2016. RESULTS: Analyses revealed concordant drinking spouses (both indicated they drank in the last 3 months) survived longer than discordant drinking spouses (1 partner drinks and the other does not) and concordant nondrinking spouses. Analysis of average drinks per week showed a quadratic association with mortality such that light drinking predicted better survival rates among individuals and their partners compared with abstaining and heavy drinking. Further, similar levels of drinking in terms of the amount of drinking were associated with greater survival, particularly among wives. DISCUSSION AND IMPLICATIONS: This study moves the field forward by showing that survival varies as a function of one's own and one's partner's drinking.

Adolescents' exposure to community violence and associations with after-school activities across two samples.

INTRODUCTION: Exposure to community violence (ECV) continues to be a major public health problem among urban adolescents in the United States. We sought to identify subgroups of adolescents' ECV and examine how after-school activities are related to exposure subgroups across two samples. METHODS: In Study 1 there were 1432 adolescents (Cohort 9 n = 717, Mage = 11, and Cohort 12 n = 715, Mage = 14; 52% boys) from the Project on Human Development in Chicago Neighborhoods (1994-2002). Study 2 had a more recent sample of 537 adolescents (Mage = 16 years; 54% girls) from the After-School Activity Study (ASAS; 2015-2017) in Chicago and Detroit. RESULTS: Exploratory latent class analyses yielded a three-class solution for Study 1: a "No ECV" class (44%); a "Low ECV" class (36%); and a "High Exposure" class (14%). In Study 2, a four-class solution was the best fit with a "No ECV" class (33%), a "Moderate Witness/Low Victim" class (36%), a "High Witness/Moderate Victim" class (19%), and a "High ECV" class (11%). Home-based activities appeared to be protective against high ECV for adolescents in Study 2. School-based activities were associated with higher ECV across both samples, but community-based activities were only associated with greater violence exposure in Study 1. Adolescents' unstructured socializing in both studies was associated with higher odds of ECV. CONCLUSIONS: Results indicate that subgroups of adolescents can be identified based on ECV and highlight the complexity of after-school activities as risk and protective factors in both past and more recent contexts.

Coagulofibrinolytic effects of recombinant soluble thrombomodulin in prolonged porcine cardiac arrest.

Aim: To evaluate coagulofibrinolytic abnormalities and the effects of ART-123 (recombinant human thrombomodulin alpha) in a porcine model of cardiac arrest and prolonged cardiopulmonary resuscitation (CA/CPR). Methods: Fifteen pigs (n = 5 per group) underwent 8 minutes of no-flow CA followed by 50 minutes of mechanical CPR, while 2 pigs underwent sham arrest. CA/CPR animals were randomized to receive saline or 1 mg/kg ART-123 pre-arrest (5 minutes prior to ventricular fibrillation) or post-arrest (2 minutes after initiation of CPR). Arterial and venous blood samples were drawn at multiple time points for blood gas analysis and measurement of plasma and whole blood markers of coagulation and fibrinolysis. Results: In saline-treated CA/CPR, but not sham animals, robust and persistent activation of coagulation and fibrinolysis was observed throughout resuscitation. After 50 minutes of CPR, plasma tests and thromboelastography indicated a mix of hypercoagulability and consumptive coagulopathy. ART-123 had a robust anticoagulant effect, reducing both thrombin-antithrombin (TAT) complexes and d-dimer (p < 0.05 for each). The duration of anticoagulant effect varied depending on the timing of ART-123 administration. Similarly, ART-123 when given prior to cardiac arrest was found to have pro-fibrinolytic effects, increasing free tissue plasminogen activator (tPA, p = 0.02) and decreasing free plasminogen activator inhibitor-1 (PAI-1, p = 0.04). Conclusion: A porcine model of prolonged CA/CPR reproduces many of the coagulofibrinolytic abnormalities observed in human cardiac arrest patients. ART-123 demonstrates a combination of anticoagulant and profibrinolytic effects, depending on the timing of its administration relative to cardiac arrest.

Impact of emergency department-based intensive care unit on outcomes of decompensating boarding emergency department patients.

Objectives: Emergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED-ICU on decompensating boarding ED patients. Methods: This is a retrospective single-center observational study. We identified decompensated boarding ED patients necessitating critical care before departure from the ED from October 2012 to December 2021. An automated query and manual chart review extracted data. Three cohorts were defined: pre-ED-ICU implementation (Group 1), post-ED-ICU implementation with ED-ICU care (Group 2), and post-ED-ICU implementation with inpatient ICU admission without ED-ICU care (Group 3). Primary outcome was ICU length of stay (LOS). Secondary outcomes included hospital LOS, in-hospital mortality, and ICU admissions with ICU LOS <24 hours. Between-groups comparisons used multiple regression analysis for continuous variables, χ2 tests and multivariable logistic regression analysis for binary variables, and follow-up contrasts for statistically significant omnibus tests. Results: A total of 1123 visits met inclusion criteria: 225 in Group 1, 780 in Group 2, and 118 in Group 3. Mean ICU LOS was shorter for Group 2 than Group 1 or 3 (47.4 vs 92.3 vs 103.9 hours, P < 0.001). Mean hospital LOS was shorter for Group 2 than Group 1 or 3 (185.1 vs 246.8 vs 257.3 hours, P < 0.01). In-hospital mortality was similar between groups. The proportion of ICU LOS <24 hours was lower for Group 2 than Group 1 or 3 (16.5 vs 27.1 vs 32.2%, P < 0.01). Conclusion: For decompensating boarding ED patients, ED-ICU care was associated with decreased ICU and hospital LOS, similar mortality, and fewer short-stay ICU admissions, suggesting ED-ICU care is associated with downstream resource preservation.

The role of trauma services in intentional self-harm at a regional level 1 trauma center.

INTRODUCTION: Suicide claims many lives globally, each year. For every person that dies by suicide, multitudes more attempt it. A national shortage of psychiatrists may prevent many individuals from receiving timely mental health care. For many individuals, the primary entry point into the healthcare system is through the emergency department. The trauma service frequently treats patients with severe self-inflicted injuries and for many this is not the first time. This represents an opportunity for intervention to disrupt the cycle and prevent future death. METHODS: We conducted a retrospective chart review of all patients with self-inflicted injuries, admitted to the trauma surgery service between 2012 and 2021. All patients above 10 years old were included. RESULTS: Four hundred forty-one patients were admitted due to self-injurious behavior in the period under study. The majority of patients (71.9%) had a pre-existing mental health disorder. Fifty six patients suffered fatal injuries; the majority were White (78.6%), males (80.3%), and were inflicted by gunshot (71.4%). Nearly one third of patients with self-inflicted injuries had a history of self-injurious behavior with the average number of attempts being 2.7 (SD: ±3.8). CONCLUSIONS: We need interdisciplinary and innovative solutions for this public health crisis. Perhaps telemedicine can be used to buttress the access to adequate mental health care. More research needs to be done to better identify the barriers individuals encounter in accessing mental health care, both pre- and post-crisis. The goal is that, by identifying the gaps, we can collaboratively bridge them to prevent a preventable death.

The Two-Bag Method for Management of Adult Diabetic Ketoacidosis-Experience With 634 Patients.

PURPOSE: To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method. MATERIALS AND METHODS: This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t-tests for continuous variables and χ2 tests for binary variables. RESULTS: We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P = .16. CONCLUSIONS: For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.

Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings.

Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools. Objective: To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE. Design, Setting, and Participants: This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022. Main Outcomes and measures: The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) . Results: Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001). Conclusions and Relevance: In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.

Treating Prehospital Pain in Children: A Retrospective Chart Review Comparing the Safety and Efficacy of Prehospital Pediatric Ketamine and Opioid Analgesia.

Prior to 2020, pain management in the Washtenaw/Livingston County Medical Control Authority (W/L MCA) Emergency Medical Service (EMS) system in Southeast Michigan was limited to morphine, fentanyl, ketorolac, and acetaminophen. Based on the increasing evidence describing its safety and efficacy, ketamine was added to local protocols for pain management. This study aimed to evaluate differences in pain management and adverse effects of ketamine and opioid administration. Data from pediatric patients who received ketamine or an opioid in the W/L MCA EMS system from October 2019 to March 2021 were analyzed. The primary outcome was the difference in pain score, and the secondary outcome was adverse effects observed after analgesic administration. The decrease in pain scores was greater among ketamine patients (mean: 5.2) compared to opioid patients (mean: 2.9), p < 0.001. The prevalence of adverse effects was higher among patients in the ketamine group (28.6%) compared to patients in the opioid group (2.4%, p < 0.001). Of 14 patients who received ketamine, one 17-year-old male experienced mild anxiety (7.1%), two teenage females experienced mild dissociation (14.3%), and one 20-year-old female experienced mild nausea (7.1%). Overall, ketamine is a safe and effective option compared to opioids for pediatric patients experiencing moderate to severe prehospital pain.

Impact of the COVID-19 Pandemic on Children and Adolescents Presenting With a Psychiatric Emergency.

This mixed-methods survey study aims to describe the effects of the COVID-19 pandemic on the mental health of a sample of 571 children and adolescent seeking psychiatric emergency care. The study was conducted from July to October 2020 at a large Midwestern academic center. Among the respondents, there were significant increases in mental health symptoms attributed to the COVID-19 pandemic, including anxiety (71% of respondents), depression (66%), suicidal thoughts or behaviors (45%), and aggression (31%). There were significant differences in reported increases in symptoms by age and gender. In addition, 38% of participants reported that the pandemic led to a change or closure of their health care treatment, including mental health providers, with 22% reporting that reduced treatment access led to their emergency visit. Further research is indicated to assess other, more diverse populations, as well as the longer-term mental health impacts of the pandemic.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis.

Introduction: Euglycemic diabetic ketoacidosis (DKA) (glucose <250 milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. Methods: This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18 years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18 millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250 milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250 mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. Results: We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561 mg/dL, P < 0.001) and potassium (4.3 vs 5.3 mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18 mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70 mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3 mmol/L) was 27.3 vs 19.1% (P = 0.23). Conclusion: Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

Cost-effectiveness of an Emergency Department-Based Intensive Care Unit.

Importance: Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care. Objective: To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter. Design, Setting, and Participants: This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021. Exposures: Implementation of an ED-ICU. Main Outcomes and Measures: Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED. Results: A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001). Conclusions and Relevance: Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.

The MedConnect Program: Symptomatology, Return Visits, and Hospitalization of COVID-19 Outpatients Following Discharge From the Emergency Department.

Background and objective Although hospitalization is required for only a minority of those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the high rates of morbidity and mortality among these patients have led researchers to focus on the predictors of admission and adverse outcomes in the inpatient population. However, there is scarce data on the clinical trajectory of individuals symptomatic enough to present for emergency care, but not sick enough to be admitted. In light of this, we aimed to examine the symptomatology, emergency department (ED) revisits, and hospitalization of coronavirus disease 2019 (COVID-19) outpatients after discharge from the ED. Methods Adult patients with COVID-19 infection were prospectively enrolled after discharge from the ED between May and December 2020. Patients were followed up longitudinally for 14 days via phone interviews designed to provide support and information and to track symptomatology, ED revisits, and hospitalization. Results A volunteer, medical student-run program enrolled 199 COVID-19 patients discharged from the ED during the first nine months of the pandemic. Of the 176 patients (88.4%) who completed the 14-day protocol, 29 (16.5%) had a second ED visit and 17 (9.6%) were admitted, 16 (9%) for worsening COVID-19 symptoms. Age, male sex, comorbid illnesses, and self-reported dyspnea, diarrhea, chills, and fever were associated with hospital admission for patients with a subsequent ED visit. For those who did not require admission, symptoms generally improved following ED discharge. Age >65 years and a history of cardiovascular disease (CVD) were associated with a longer duration of cough, but generally, patient characteristics and comorbidities did not significantly affect the overall number or duration of symptoms. Conclusions Nearly one in five patients discharged from the ED with COVID-19 infection had a second ED evaluation during a 14-day follow-up period, despite regular phone interactions aimed at providing support and information. More than half of them required admission for worsening COVID-19 symptoms. Established risk factors for severe disease and self-reported persistence of certain symptoms were associated with hospital admission, while those who did not require hospitalization had a steady improvement in symptoms over the 14-day period.

Variability in emergency department management of hypothermic infants ≤90 days of age.

OBJECTIVES: Hypothermic infants are at risk for serious bacterial and herpes simplex virus infections, but there are no evidence-based guidelines for managing these patients. We sought to characterize variations and trends in care for these infants in the emergency department (ED). METHODS: We conducted a retrospective cross-sectional study of infants under 90 days old presenting to 32 pediatric EDs from 2009 through 2019 with an International Classification of Diseases diagnosis code for hypothermia. We characterized variation in diagnostic testing, antimicrobial treatment, and disposition of children in three age groups (≤30 days, 31-60 days, and 61-90 days old) and analyzed care trends. RESULTS: Of 7828 ED encounters meeting inclusion criteria, most (81%) were ≤ 30 days of age. Infants in the 0-30 days old age group, compared to 61-90 days old age group, had a higher proportion of blood (75% vs. 68%), urine (72% vs. 64%), and cerebrospinal fluid (CSF; 35% vs. 22%) cultures obtained (p < 0.01) and greater antimicrobial use (81% vs. 68%; p < 0.01) in the ED. From 2009 to 2019, C-reactive protein (CRP), and procalcitonin usage steadily increased, from 25% to 40% and 0% to 30% respectively, while antibiotic use (83% to 77%), CSF testing (53% to 44%), and chest radiography (47% to 34%) decreased. Considerable interhospital variation was noted in testing and treatment, including CSF testing (14-70%), inflammatory markers (CRP and procalcitonin; 8-88%), and antibiotics (56-92%). CONCLUSION: Substantial hospital-level variation exists for managing hypothermic infants in the ED. Long-term trends are notable for changing practice over time, particularly with increased use of inflammatory markers. Prospective studies are needed to risk stratify and optimize care for this population.

Use of an Electronic Referral Application to Address Post-Injury Needs of Victims of Firearm Injury in a Hospital-Based Violence Intervention Program.

BACKGROUND: Wraparound referrals are a cornerstone of hospital-based violence intervention programs, which have proven to be an effective public health approach for mitigating violence and recidivism. We hypothesized that replacing a manual referral process with an electronic referral application would increase the number of generated referrals and improve compliance with follow-up visits. STUDY DESIGN: The population for this single center quantitative study was a convenience sample of firearm-injured patients. Data from 74 patients were collected using the electronic health record, the electronic referral application, and the trauma registry before and after the intervention. RESULTS: Post-implementation of the electronic referral application showed an increased number of generated referrals, increased emergency department and inpatient utilization of trauma recovery center services, and an increase in second follow-up visit compliance. CONCLUSION: This study demonstrated an increase in the number of referrals and greater likelihood of completion of post-injury follow-up visits after implementing the electronic referral system.

Emergency department length of stay and outcomes of emergency department-based intensive care unit patients.

OBJECTIVE: Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED-based intensive care units (ED-ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED-ICU on patient outcomes. METHODS: We retrospectively analyzed adult ED patients managed in the ED-ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48-hour mortality, and hospital mortality. Multivariable analyses' covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). RESULTS: We included 5859 ED visits with subsequent care in the ED-ICU. Median age, CCI, eSAPS3, ED LOS, and ED-ICU LOS were 62 years (interquartile range [IQR], 48-73 years), 5 (IQR, 2-8), 46 (IQR, 36-56), 3.6 hours (IQR, 2.5-5.3 hours), and 8.5 hours (IQR, 5.3-13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (ß = -3.4; 95% confidence interval [CI], -5.9 to -1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84-0.88), 48-hour mortality (OR, 0.89; 95% CI, 0.82-0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85-0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88-0.93), but no associations with other outcomes. CONCLUSIONS: We observed no significant associations between ED LOS before ED-ICU transfer and worsened outcomes, suggesting an ED-ICU may mitigate the risks of ED boarding of patients who are critically ill.

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

An in-depth look at ventilator-associated pneumonia in trauma patients and efforts to increase bundle compliance, education and documentation in a surgical trauma critical care unit.

BACKGROUND: Ventilator-associated pneumonia (VAP) is considered the most common hospital acquired infection seen in critical care settings and leading cause of death in Intensive Care Units (ICU). The objective of this study was to assess whether specimen collection impacted diagnosis and if implementation of a VAP bundle would decrease rates at our center. METHODS: This single center study design is a retrospective chart review from 2017 to 2020 utilizing the electronic medical record. A pre-/postintervention comparison was performed following implementation of a unit wide VAP bundle and nursing education. Descriptive statistics and continuous variables were analyzed with independent group t -tests, and categorical variables were analyzed with chi-squared tests. RESULTS: Ventilator-associated pneumonia rates decreased in the postimplementation time (20.8%, n = 74 vs 12.2%, n = 15; P = .03). There were no significant differences in the patient profile of those who acquired VAP (ie, males 79.7% vs 86.7%, blunt injuries 63.5% vs 86.7% and severity scores 24.8 vs 25.1, pre vs postimplementation, respectively, all P-values greater than .05). DISCUSSION/CONCLUSIONS: Reduction in VAP rates were achieved by implementing a standardized, evidence based, prevention protocol. Further research is warranted as studies have noted that patients requiring mechanical ventilation are at greater risk for VAP than other ICU patients due to the nature of their injuries and increased risk of prolonged mechanical ventilation ≥ 21 days.