Impact of skilled nursing facility (SNF) 3-day hospitalization requirement waiver during the COVID-19 pandemic on emergency department and inpatient SNF discharges in California.

Objective: We sought to study the impact of the Centers for Medicare & Medicaid services (CMS) waiver of the 3-day hospitalization requirement for skilled nursing facility (SNF) care implemented as part of the Federal COVID-19 response on emergency department (ED) and inpatient hospital SNF discharges. Methods: We conducted a multicenter retrospective cohort study of hospital ED and inpatient visits in California during 18 months before (prewaiver, September 2018-February 2020) and 18 months after (waiver, March 2020-August 2021) waiver implementation. Data were collected from all adult ED and admitted patients utilizing California Department of Health Care Access and Information datasets from all acute care hospitals licensed in the state. Prewaiver and waiver periods were compared for SNF discharge/disposition rates stratified by patient demographic and hospital data with differences in the proportion and 95% confidence interval [CI] reported (SPSS). Results: SNF discharges decreased from the prewaiver to waiver periods from the ED (-7.4% [CI -8.1%, -6.6%]), along with larger declines occurring from the inpatient hospital setting (-18.1% [CI -18.4%, -17.9%]). For Medicare beneficiaries, there was a smaller decrease in ED SNF rates (-3.8% [CI -4.7%, -2.9%]), and there was no significant change for SNF discharge rates for inpatient admissions with a length of stay (LOS) <3 days (+1.0% [CI 0.0%, 2.1%]). Conclusion: In California, the CMS waiver did not result in an increase, but an actual decrease rate of SNF discharges from the ED and inpatient setting, though with smaller declines for the ED, Medicare patients, and those with a LOS <3 days.

Impact of Implementation of a New Weapons Screening at an Urban Emergency Department.

BACKGROUND: Violence in the emergency department (ED) setting is well documented in medical literature. Weapons can be used to cause significant injury or mortality, although there is a paucity of literature on weapons and weapons screening in the ED. OBJECTIVES: The purpose of this study was to assess the impact of initiating a weapons screening process on the identification and removal of weapons. METHODS: Multiple aspects of a weapons screening program were evaluated at 2 and 6 months prior to and after a weapons screening protocol was initiated at an urban ED. In the Pre-Screen periods, only patients primarily seeking care for mental health were screened prior to entry. In the Post-Screen periods, all patients and visitors were screened with walk-through magnetometers or wand metal detectors, and additional screening checks were initiated. The number of individuals screened and numbers of weapons found were measured. Descriptive statistics comparing Pre- and Post-Screen periods were performed. RESULTS: Prior to the new screening process, 511 and 1701 patients primarily seeking care for mental health were screened, with 15 and 103 weapons confiscated at 2 and 6 months, respectively. After the screening process was initiated, 13,149 and 43,321 ED patients and visitors were screened, with 194 and 567 weapons confiscated at 2 and 6 months, respectively. Persons screened increased by 25-fold at both 2 and 6 months after implementing the screening process. Weapons confiscated increased approximately 13-fold and sixfold at the respective 2- and 6-month Pre- and Post-Screen periods, respectively. CONCLUSION: Implementation of weapons screening significantly increased the number of weapons identified and confiscated prior to entry in the ED by patients and visitors.

Clinical and financial outcome impacts of comprehensive geriatric assessment in a level 1 geriatric emergency department.

BACKGROUND: The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED. METHODS: This is a retrospective matched case-control study at a level 1 geriatric ED (GED) from January 1, 2018-March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective. RESULTS: GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] -17.0%, -9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90-days post discharge (-11.3%, 95% CI -15.6%, -7.1%, p-value < 0.001; and -10.0, 95% CI -13.8%, -6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit. CONCLUSIONS: GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings.

Trends in emergency department visits associated with cannabis use among older adults in California, 2005-2019.

BACKGROUND: The use of cannabis among older adults is increasing in the United States. While cannabis use has been suggested to help alleviate chronic symptoms experienced by older adults, its potential adverse effects may lead to unintended consequences, including increased acute healthcare utilization related to its use. The objective of this study was to examine trends in cannabis-related emergency department (ED) visits in California. METHODS: Using data from the Department of Healthcare Access and Information, we conducted a trend analysis of cannabis-related ED visits from all acute care hospitals in California from 2005 to 2019. For each calendar year, we determined the cannabis-related ED visit rate per 100,000 ED visits for adults aged ≥65 utilizing primary or secondary diagnosis codes. We estimated the absolute and relative changes in overall cannabis-related visit rates during the study period and by subgroup, including age (65-74, 75-84, ≥85), race/ethnicity, sex, payer/insurance, Charlson comorbidity index score, and cannabis-related diagnosis code. RESULTS: The cannabis-related ED visit rate increased significantly for adults aged ≥65 and all subgroups (p < 0.001). The overall rate increased from 20.7 per 100,000 visits in 2005 to 395.0 per 100,000 ED visits in 2019, a 1804% relative increase. By race/ethnicity, older Black adults had the highest ED visit rate in 2019 and the largest absolute increase while older males had a higher ED visit rate in 2019 and a greater absolute increase than older women. Older adults with a higher Charlson score had a higher ED visit rate in 2019 and a larger absolute increase during the study period. CONCLUSION: Cannabis-related ED visits are increasing among older adults in California and are an adverse effect of cannabis use. Asking about cannabis use and providing education about its use should be a part of routine medical care for older adults.

A retrospective review of antibiotic use for acute respiratory infections in urgent-care patients.

Objective: We examined the use of antibiotics for acute respiratory infections in an urgent-care setting. Design: Retrospective database review. Setting: The study was conducted in 2 urgent-care clinics staffed by academic emergency physicians in San Diego, California. Patients: Visits for acute respiratory infections were identified based on presenting complaints. Methods: The primary outcome was a discharge prescription for an antibiotic. The patient and provider characteristics that predicted this outcome were analyzed using logistic regression. The variation in antibiotic prescriptions between providers was also analyzed. Results: In total, 15,160 visits were analyzed. The patient characteristics were not predictive of antibiotic treatment. Physicians were more likely than advanced practice practitioners to prescribe antibiotics (1.31; 95% confidence interval [CI], 1.21-1.42). For every year of seniority, a provider was 1.03 (95% CI, 1.02-1.03) more likely to prescribe an antibiotic. Although the providers saw similar patients, we detected significant variation in the antibiotic prescription rate between providers: the mean antibiotic prescription rate within the top quartile was 54.3% and the mean rate in the bottom quartile was 21.7%. Conclusions: The patient and provider characteristics we examined were either not predictive or were only weakly predictive of receiving an antibiotic prescription for acute respiratory infection. However, we detected a marked variation between providers in the rate of antibiotic prescription. Provider differences, not patient differences, drive variations in antibiotic prescriptions. Stewardship efforts may be more effective if directed at providers rather than patients.

Urine testing is associated with inappropriate antibiotic use and increased length of stay in emergency department patients.

Background: Exposing patients with a low probability of disease to diagnostic testing with poor test characteristics leads to false positive results. Providers often act on these false results, which can cause unnecessary evaluation and treatment. The treatment of asymptomatic bacteriuria is discouraged, but it still frequently occurs in the inpatient setting; it is less studied in the Emergency Department (ED). In this study, we examine associations between urine testing, inappropriate antibiotic use, and length of stay in discharged ED patients at risk of urinary tract infection (UTI) misdiagnosis. Methods: A cohort of discharged ED patients at risk of UTI misdiagnosis was created by pulling visit information for patients presenting with abdominal pain, chest pain, headache, vaginal bleeding in pregnancy, and elderly females with weakness or confusion. Predictors of urine testing, and urinary tract infection treatment were determined with logistic regression analysis. A chart review of a representative sample of this cohort was then completed screening for the presence of urinary tract symptoms and urine culture results. Linear regression analysis was then used to generate an adjusted mean difference in length of stay between patients who had urine testing compared to those who did not. Results: About a quarter of chest pain and headache patients had urine testing, while approximately 75% of abdominal pain patients, vaginal bleeding in pregnancy, and elderly females with weakness or confusion did. Except for chest pain patients, the UTI treatment rate was more than double the positive culture rate, indicating overtreatment. A diagnosis of UTI is based on a combination of UTI symptoms and positive urine cultures, yet only about 15% of patients treated for UTI met these criteria. Lastly, in all chief complaint groups, the length of stay was significantly longer-30 min or more-for those who had urine testing compared to matched controls. Conclusions: In this observational study of patients at risk of UTI misdiagnosis, urine testing was associated with inappropriate antibiotic use and delayed discharge. There is pressure on providers to perform diagnostic testing, but in patients without specific UTI symptoms, urine testing might cause more harm than benefit.

Geriatric Falls: Patient Characteristics Associated with Emergency Department Revisits.

INTRODUCTION: Falls are the leading cause of traumatic injury among elderly adults in the United States, which represents a significant source of morbidity and leads to exorbitant healthcare costs. The purpose of this study was to characterize elderly fall patients and identify risk factors associated with seven-day emergency department (ED) revisits. METHODS: This was a multicenter, retrospective, longitudinal cohort study using non-public data from 321 licensed, nonfederal, general, and acute care hospitals in California obtained from the Department of Healthcare Access and Information from January 1-December 31, 2017. Included were patients 65 and older who had a fall-related ED visit identified by International Classification of Diseases codes W00x to W19x. Primary outcome was a return visit to the ED within a seven-day window following the index encounter. Demographics collected included age, gender, ethnicity/race, patient payer status, Charlson Comorbidity Index (CCI), psychiatric diagnoses, and alcohol/substance use disorder diagnoses. We performed multivariate logistic regression to identify characteristics associated with seven-day ED revisit. RESULTS: We identified a total of 2,758,295 ED visits during the study period with 347,233 (12.6%) visits corresponding to fall-related injuries. After applying exclusion criteria, 242,572 index ED visits were identified, representing 206,612 patients. Of these, 24,114 (11.7%) patients returned to an ED within seven days (revisit). Within this revisit population, 6,161 (22.6%) presented to a facility that was distinct from their index visit, and 4,970 (18.2%) were ultimately discharged with the same primary diagnosis as their index visit. Characteristics with the largest independent associations with a seven-day ED revisit were presence of a psychiatric diagnosis (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.69 to 1.80), presence of an alcohol or substance use disorder (OR 1.70; 95% CI 1.64 to 1.78), and CCI ≥ 3 (OR 2.79; 95% CI 2.68 to 2.90). CONCLUSION: In this study we identified 24,114 elderly fall patients who experienced a seven-day ED revisit. Patients with multiple comorbidities, a substance use disorder, or a psychiatric diagnosis exhibited increased odds of experiencing a return visit to the ED within seven days of a fall-related index visit. These findings will help target at-risk elderly fall patients who may benefit from preventative multidisciplinary intervention during index ED visits to reduce ED revisits.

Heat Waves and Emergency Department Visits Among the Homeless, San Diego, 2012-2019.

Objectives. To determine the effect of heat waves on emergency department (ED) visits for individuals experiencing homelessness and explore vulnerability factors. Methods. We used a unique highly detailed data set on sociodemographics of ED visits in San Diego, California, 2012 to 2019. We applied a time-stratified case-crossover design to study the association between various heat wave definitions and ED visits. We compared associations with a similar population not experiencing homelessness using coarsened exact matching. Results. Of the 24 688 individuals identified as experiencing homelessness who visited an ED, most were younger than 65 years (94%) and of non-Hispanic ethnicity (84%), and 14% indicated the need for a psychiatric consultation. Results indicated a positive association, with the strongest risk of ED visits during daytime (e.g., 99th percentile, 2 days) heat waves (odds ratio = 1.29; 95% confidence interval = 1.02, 1.64). Patients experiencing homelessness who were younger or elderly and who required a psychiatric consultation were particularly vulnerable to heat waves. Odds of ED visits were higher for individuals experiencing homelessness after matching to nonhomeless individuals based on age, gender, and race/ethnicity. Conclusions. It is important to prioritize individuals experiencing homelessness in heat action plans and consider vulnerability factors to reduce their burden. (Am J Public Health. 2022;112(1):98-106. https://doi.org/10.2105/AJPH.2021.306557).

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes.

INTRODUCTION: There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits. METHODS: This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition. RESULTS: Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22-24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%). CONCLUSION: In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

BACKGROUND: There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). OBJECTIVE: To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. METHODS: A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. RESULTS: Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. CONCLUSION: Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.

Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department.

BACKGROUND: There is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults. METHODS: This was a retrospective cohort study within two geriatric emergency departments (GEDs) at a large academic health system. One hundred patients 65 years or older who visited a GED between March 10, 2020 and August 9, 2020 and tested positive for COVID-19 were examined. Electronic medical records were used to determine presenting COVID-19-related symptoms, comorbidities, and clinical outcomes. Descriptive statistics are reported with associated 95% confidence intervals (CIs). RESULTS: In the overall sample, mean age was 75.9 years; 18% were 85 years or older; 50% were male; and 46.0% were Hispanic. Relative to non-Hispanic patients with COVID-19, Hispanic patients with COVID-19 had a higher percentage of shortness of breath (78.3% vs. 51.9%; difference: 26.4%; 95% CI 7.6-42.5%), pneumonia (82.6% vs. 50.0%; difference: 32.6%; 95% CI 14.1-47.9%), acute respiratory distress syndrome (13.0% vs. 1.9%; difference: 11.1%; 95% CI 0.7-23.9%), and acute kidney failure (41.3% vs. 22.2%; difference: 19.1%; 95% CI 0.9-36.0%). Rates of other poor outcomes, including hospitalization, intensive care unit (ICU) admission, return visits to the GED within 30 days of discharge, or death, did not significantly differ between Hispanic and non-Hispanic patients with COVID-19. CONCLUSIONS: These preliminary data show that older Hispanic patients relative to non-Hispanic patients with COVID-19 presenting to a GED did not experience worse outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death.

Age-related incidence and outcomes of sepsis in California, 2008-2015.

PURPOSE: Sepsis remains amongst the most common causes of death worldwide. It has been described as a disease of the elderly, but contemporary data on risk factors and mortality is lacking. MATERIALS AND METHODS: Multi-center longitudinal cohort study using non-public, state of California data from January 1, 2008 to September 31, 2015. Patients with sepsis, severe sepsis, and septic shock were identified using ICD-9-CM diagnosis and procedure codes with age subgroups of 18-44, 45-64, 65-74, 75-84, and >85 years old. Descriptive statistics and a single direct logistic regression model were used to present data on incidence and mortality and to identify independent factors associated with mortality. RESULTS: Of 30,282,159 total inpatient encounters, 20,358,569 met inclusion criteria and 1,566,306 met sepsis criteria. Conditions associated with mortality included metastatic cancer, age, liver disease, residing in a care facility, and a gastrointestinal source of infection as well as fungal infection. Mortality in the >85-year-old subgroup with septic shock was 45.7%, lower than previously reported. CONCLUSION: Age remains an important sepsis risk factor, but other conditions correlated more closely with sepsis-associated death. Patients over 85 years of age suffering from septic shock may have a better chance of survival than previously thought.

Barriers to medication adherence in the emergency department: A cross-sectional study.

BACKGROUND: Medication nonadherence is a common problem that leads to increased healthcare utilization. It is unclear how patient insight and attitude towards their medications affect adherence in the ED. Furthermore, it is unclear how perceived medication importance differs between patients and ED physicians. METHODS: We conducted a cross sectional study of adult patients presenting to 2 academic emergency departments from April 2015 to October 2016. Demographic data were collected and questions were asked regarding medication knowledge, perceived importance, and adherence. We also compared perceived importance of medications between patients and two physician raters. Inter-rater agreement was reported as raw percentages, and categorical data were compared using chi-squared analysis. RESULTS: We identified 1268 patients, representing 4634 individual medications. We identified a significant association between knowledge of medications and perceived importance (p < .05). Secondarily, importance level was highly associated with medication adherence (p < .05). When ranking those medications that were considered "least" and "most" important among each patient's med list, our two physicians agreed with patients only 34.1% and 37% of the time respectively, as opposed to 62% and 62.8% agreement between each other. CONCLUSIONS: These data suggest that there is a difference in perceived medication importance between ED physicians and ED patients. Knowledge of a medication's purpose is significantly associated with perceived importance, while this importance appears to be significantly associated with compliance. These results suggest that concerted efforts by ED physicians and staff to educate patients on the utility and importance of their medications may improve adherence.

The effects of a morphine shortage on emergency department pain control.

OBJECTIVE: In 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition. METHODS: This was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17-6/30/17 and our study period (without morphine) was 4/1/18-6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition. RESULTS: We identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study -3.30, control -3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01). CONCLUSIONS: Removing IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.

Clinical Features of Patients with COVID-19: is Temperature Screening Useful?

BACKGROUND: As many businesses reopen after government-induced restrictions, many public agencies and private companies, such as banks, golf courses, and stores, are using temperature screening to assess for possible coronavirus disease 2019 (COVID-19) infection both for patrons and for employees. OBJECTIVE: We assessed the frequency of a fever ≥100.4°F and other symptoms associated with COVID-19 among patients in the emergency department (ED) who were tested in the ED for the illness. METHODS: This is a retrospective review of data from patients who were tested for acute COVID-19 infection from March 10, 2020 through June 30, 2020 at two EDs within the same health care system. Data collected included temperature, the presence or recent history of COVID-19-related symptoms, and COVID-19 test results. Descriptive statistics are reported for presenting fever and other COVID-19-related symptoms alone and in combination with presenting fever. RESULTS: A total of 6894 patients were tested for COVID-19. Among these, 330 (4.8%) tested positive for active infection. Of these patients, 64 (19.4%) presented with a fever ≥100.4°F (≥38.0°C). Increasing the number of COVID-19-related symptoms in combination with a presenting fever ≥100.4°F increased the number of people who could be identified as having a COVID-19 infection. CONCLUSIONS: About a quarter of patients who were tested positive for COVID-19 in our ED did not have a fever at presentation ≥100.4°F. Using only temperature to screen for COVID-19 in the community setting will likely miss the majority of patients with active disease.

Rates of coinfection with other respiratory pathogens in patients positive for coronavirus disease 2019 (COVID-19).

Objectives: The purpose of this study was to assess coinfection rates of coronavirus disease 2019 (COVID-19) with other respiratory infections on presentation. Methods: This is a retrospective analysis of data from a 2 hospital academic medical centers and 2 urgent care centers during the initial 2 weeks of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), March 10, 2020 to March 23, 2020. Testing was targeted toward high-risk patients following US Centers for Disease Control and Prevention guidelines. Demographics include age group and sex. Laboratory test results included SARS-CoV-2, rapid influenza A/B, and upper respiratory pathogen nucleic acid detection. Patient demographics and coinfections are presented overall and by test results with descriptive statistics. Results: Complete laboratory results from the first 2 weeks of testing were available for 471 emergency department patients and 117 urgent care center patients who were tested for SARS-CoV. A total of 51 (8.7%) patients tested positive for COVID-19 with only 1 of these patients also testing positive for another respiratory infection. One of the patients positive for COVID-19 also tested positive for influenza A. Among the 537 patients who were screened and tested negative for COVID-19, there were 33 (6.1%) patients who tested positive in the upper respiratory pathogen nucleic acid detection test. Conclusion: In our study investigating coinfections among 51 patients testing positive for COVID-19, 1 patient also tested positive for influenza A. Although we found limited coinfections in our emergency department and urgent care center patient populations, further research is needed to assess potential coinfection in patients with COVID-19.

Frequent Emergency Department Visitors Associated With a Pain-Discharge Diagnosis.

BACKGROUND: Emergency departments (EDs) have experienced an increase in annual patient visits and length of stay over the past decade. Management of frequent-user patients with pain-related diagnoses are challenging in a time-limited setting. OBJECTIVE: The purpose of this study was to describe characteristics of frequent ED users with pain-related diagnoses. METHODS: This was a retrospective longitudinal cohort study of hospital ED visits from two EDs in using encounters from September 2016 to August 2018. Frequent users were characterized as having four or more visits in a 1-year period and were further classified into three categories based on the number of pain-related visits in the study period. Descriptive statistics and regression analysis results are reported for all demographic and clinical characteristics for index encounters, patient level data, and pain subgroups. RESULTS: Of all patients, 11.3% (n = 5174) were identified as frequent users, accounting for 38.9% (n = 91,114) of all ED visits. Overall, frequent pain users were more likely to be of middle age (odds ratio [OR] 1.70, 95% confidence interval [CI] 0.80-1.72), female (OR 2.43, 95% CI 1.79-3.29), have commercial insurance (OR 1.91, 95% CI 1.37-2.66), and have 10 or more ED encounters (super user status) in a 12-month period (OR 23.66, 95% CI 17.12-32.71). CONCLUSION: Understanding characteristics of ED frequent users with pain-related diagnoses may inform community-based interventions designed to reduce episodic care and thereby improve care coordination and management.

Further study on the physiological effects of an alternative spit mask.

OBJECTIVES: Spit masks are used by law enforcement officers and healthcare providers to protect themselves from the spread of communicable disease by subjects who pose a potential risk of biological exposure by spitting. Little research is available regarding the safety of these masks. However, concerns surround the ability of subjects to properly ventilate while wearing these masks as there are several anecdotal incidents of asphyxiation. A recent pilot study performed by our group showed no significant changes in ventilatory or circulatory parameters in healthy adults wearing a standard spit mask. In this study we aim to further this baseline research by testing physiological parameters in subjects wearing an alternative design of spit mask. METHODS: This prospective study evaluated the changes in respiratory and circulatory parameters in healthy adult subjects wearing a Safariland Tranzport Hood spit mask (SKU: 8320-0-2C) at rest. Baseline measurements of pulse, blood pressure, respiratory rate, oxygen saturation, and end-tidal CO2 were taken while sitting at rest. The spit mask was then placed over the subject's head and repeat measurements were taken at 5, 10, and 15 min. Measurements at 5, 10, and 15 min were compared to baseline using paired t tests with 95% confidence intervals using SPSS. RESULTS: A total of 15 subjects participated in the study. There was no significant difference between baseline and at 5, 10, and 15 min after spit mask application in heart rate (p = 0.246, p = 0.785, p = 0.502, respectively), oxygen saturation (p = 0.751, p = 0.334, p = 1.00, respectively), respiratory rate (p = 0.866, p = 0.270, p = 0.106, respectively), systolic blood pressure (p = 0.385, p = 0.481, p = 0.182, respectively), and diastolic blood pressure (p = 0.832, p = 0.516, p = 0.597, respectively). For end-tidal CO2, there was no significant difference between baseline and at 10 and 15 min (p = 0.586, p = 0.416, respectively). End-tidal CO2 was significantly increased from baseline at 5 min (p = 0.042). CONCLUSIONS: In healthy adult subjects, there were no clinically significant differences in respiratory or circulatory parameters while wearing the Safariland Tranzport Hood spit mask.

Trends in emergency physician opioid prescribing practices during the United States opioid crisis.

BACKGROUND: Prescription opioid related deaths have increased dramatically over the past 17 years. Although emergency physicians (EPs) have not been the primary force behind this rise, previous literature have suggested that EPs could improve their opioid prescribing practices. We designed this study to evaluate the trend in emergency department (ED) opioid prescriptions over time during the US opioid epidemic. METHODS: We conducted a retrospective cohort study from July 1, 2012 to June 30, 2018, evaluating all adult patients who presented to two study EDs for a pain-related complaint and received an analgesic prescription upon ED discharge. We compared these data to trends in lay media and medical literature regarding the opioid epidemic. We also evaluated the incidence of repeat ED visits based on the type of analgesic prescriptions provided. RESULTS: Opioid prescriptions decreased from 37.76% to 13.29% over the six year study period. This coupled with an increase in non-opioid medications from 6.12% to 11.33% and an increase in "no prescription" from 56.12% to 75.37%. This corresponded with an increase in the number of publications on the opioid epidemic within the lay-public and medical literature. Additionally, those patients that received no opiates were less likely to require a repeat ED visit. CONCLUSIONS: ED physicians are prescribing less opiates, while increasing the amount of non-narcotic analgesic prescriptions. This may be in response to the literature suggesting that prescription opioids play a large role in the opioids crisis. This decrease in opioid prescriptions did not increase the need for repeat ED visits.

Utility of Shunt Series in the Evaluation of Ventriculoperitoneal Shunt Dysfunction in Adults.

BACKGROUND: When patients present to emergency departments (EDs) with symptoms suspicious for ventriculoperitoneal shunt malfunction, evaluation often includes imaging of the shunt with both computed tomography (CT) of the head without contrast and a plain radiograph "shunt series" (SS). Recent literature has called into question the diagnostic value of the SS for the detection of ventriculoperitoneal shunt complications, suggesting that the plain radiographs provide redundant information and unnecessary exposure to radiation. OBJECTIVE: The aim of our study was to assess the frequency of abnormal SS plain radiography and head CT in the evaluation of shunt malfunction in all adult ED patients and to measure the association of abnormalities on CT and SS with surgical intervention. METHODS: We performed a retrospective chart review of all emergency department encounters at an urban level I trauma center between August 1, 2013 and October 3, 2018 in which an SS and head CT examination were performed within 24 h of each other. We described the results of imaging studies qualitatively and descriptive statistics were performed. RESULTS: Positive findings on CT were significantly associated with the decision to proceed to surgery. Positive findings on SS, however, were not significantly associated with the decision to proceed to surgery. CONCLUSIONS: The potential information gained from SS and convenience of ordering simultaneously with head CT does not appear to outweigh the risk of increased radiation exposure to the patient, the additional costs of the study, and the potential delay in time to head CT. These findings support the initial use of head CT in evaluation of shunt malfunction.