Prevalence and Correlates of Unmet Medical and Social Needs in Virginia's Medicaid Managed Long Term Services and Supports Program.

BACKGROUND: Medicaid Long Term Services and Support (LTSS) programs serve individuals with complex medical and social needs. Increasingly, state Medicaid programs are contracting with managed care organizations to administer LTSS programs. OBJECTIVES: Understand the prevalence of and risk factors for unmet medical and social needs among a sample of patients within a Medicaid managed LTSS program. METHODS: We surveyed a cross-sectional random sample of 798 community-residing individuals over 21 in Virginia who were served by the state Medicaid managed LTSS program. Outcomes of interest include 3 distinct medical needs: medical appointments, medical transportation, and prescriptions; 4 distinct social needs: housing security, food security, utility bills, and nonmedical transportation, and composite measures of unmet social and medical needs. RESULTS: We found that 12.5% of our sample had any unmet medical need, while far more (62.2%) of our sample had any unmet social needs, with food insecurity being the most common. We found that members of color had almost 2 times the odds of having both unmet social and medical needs [social: adjusted odds ratio (aOR): 2.21; 95% confidence Interval (CI): (1.59, 3.09); medical aOR: 2.25 ; 95% CI: (1.34, 3.8)]. CONCLUSION: Medicaid members may not be fully realizing the potential of LTSS programs and would benefit from both Medicaid agency and managed care organizations' strategies aimed at addressing social drivers of health. To achieve health equity for LTSS members of color, Medicaid agencies may consider policies specifically targeting racial disparities.

The Effect of COVID-19 on Dual-Eligible Beneficiaries: A Scoping Review.

OBJECTIVES: To examine the impact of COVID-19 on clinical health outcomes and health-related social needs among Medicaid-Medicare dual-eligible beneficiaries. DESIGN: Scoping review. SETTING AND PARTICIPANTS: Dual eligibles during COVID-19. METHODS: We performed a comprehensive scoping review including observational studies, clinical trials, and original empirical research studies of PubMed and CINAHL. We generated a list of terms related to programs that both serve dual eligibles and address our desired outcomes. With the assistance of a medical librarian, we identified relevant abstracts published during COVID-19 meeting our inclusion criteria. We performed full-text reviews of relevant abstracts and selected the final studies. We extracted the study population, design, and major findings, then conducted thematic analysis. RESULTS: 1100 articles were identified, with 439 deemed relevant. On full text-review, 15 articles met inclusion criteria representing more than 86 million Medicare beneficiaries. No studies were specific only to dual eligibles. Topic areas included in this review include COVID-19 case counts (2 articles), mortality (8 articles), hospitalizations (7 articles), food insecurity (1 article), self-reported mental health (1 article), and social connectedness (2 articles). Dual eligibles had disparate COVID-19-related outcomes from Medicare-only enrollees in 12 of 15 studies. Studies show higher mortality for dual eligibles overall, but this was not true for dual eligibles in nursing homes and assisted living communities. Dual eligibles were more likely to experience food insecurity. More favorably, dual eligibles reported greater social connectedness. CONCLUSIONS AND IMPLICATIONS: Dual eligibles had different outcomes from Medicare-only recipients in multiple health outcomes and health-related social needs during COVID-19, but studies are limited, particularly in terms of health-related social needs. Future work focusing on outcomes only among dual-eligible beneficiaries, integrated care programs, and fiscal alignment between Medicare and Medicaid plans may help stakeholders address health needs specific to dual eligibles.

Associations Between Patient-Reported Experiences with Opioid Use Disorder Treatment and Unmet Treatment Needs and Discontinuation Among Virginia Medicaid Members.

BACKGROUND: Many payers, including Medicaid, the largest payer of opioid use disorder (OUD) treatment, are pursuing treatment-related quality improvement initiatives. Yet, how patient-reported experiences with OUD treatment relate to patient-centered outcomes remains poorly understood. AIM: To examine associations between Medicaid members' OUD treatment experiences, outpatient treatment settings, demographic and social factors, and members' self-report of unmet needs during treatment and treatment discontinuation. METHODS: A sample of Virginia Medicaid members aged 21 years or older with OUD diagnoses who received outpatient OUD treatment completed a mail survey between January 2020 and August 2021 (n = 1042, weighted n = 9244). A treatment experience index was constructed from responses to four items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) relating to feelings of involvement, safety, and respect and having treatment explained in an understandable way; two additional CAHPS items: "given options for treatment" and "able to refuse treatment" were also assessed. Weighted imputed logistic regressions tested adjusted associations between members' treatment experiences, demographic and social factors, and two outcomes capturing unmet needs during treatment and treatment discontinuation. RESULTS: More positive scores on the treatment experiences index were associated with lower adjusted odds of reporting unmet needs during treatment (aOR: 0.52, 95% CI: 0.41-0.66) and discontinuation (aOR: 0.63, 95% CI: 0.47-0.79). Respondents with serious psychological distress had higher odds of reporting unmet needs during treatment (aOR: 1.69 95% CI: 1.14-2.51) and discontinuation (aOR: 1.84, 95% CI: 1.21-2.82), as did individuals with housing insecurity (unmet needs: (aOR: 1.65, 95% CI: 1.11-2.44); treatment discontinuation: (aOR: 1.56, 95% CI: 1.04-2.36)). CONCLUSION: Using a first-of-its-kind survey of Medicaid members with OUD, we found that members who had more positive treatment experiences were less likely to report unmet treatment needs and discontinue treatment. Care approaches focused on improving patient experience are critical to delivering effective, high-quality OUD treatment.

Sentanyl: a comparison of blood fentanyl concentrations and naloxone dosing after non-fatal overdose.

INTRODUCTION: Non-pharmaceutical fentanyl and its analogs have driven striking increases in opioid-associated overdose deaths. These highly potent opioids can be found at low concentrations in biological specimens. Little is known regarding the concentrations of these substances among survivors of non-fatal overdoses. In a locale where fentanyl is responsible for the majority of non-fatal opioid overdoses, we compared the concentration of fentanyl in blood to naloxone dosing in the presence and absence of a concurrent sedative-hypnotic exposure. METHODS: In this pilot study, we enrolled adult patients presenting to the emergency department (ED) who: (1) arrived after an overdose requiring naloxone for the reversal of respiratory depression; and (2) who required venipuncture or intravenous access as part of their clinical care. Blood specimens (n = 20) underwent comprehensive toxicology testing, including the quantitation of fentanyl, fentanyl analogs, and naloxone, as well as the detection of common sedative-hypnotics and a wide range of other illicit and pharmaceutical substances. We then compared fentanyl concentrations to naloxone dosing in participants with and without a concomitant sedative-hypnotic exposure. RESULTS: Nineteen of twenty participants (95%) were exposed to fentanyl prior to their overdose; the remaining participant tested positive for heroin metabolites. No participants reported pharmaceutical fentanyl use. Fentanyl analogs - acetylfentanyl or carfentanil - were present in three specimens. In 11 cases, fentanyl and its metabolites were the only opioids identified. Among the fentanyl-exposed, blood concentrations ranged from <0.1-19 ng/mL with a mean of 6.2 ng/mL and a median of 3.6 ng/mL. There was no relationship between fentanyl concentration and naloxone dose administered for reversal. We detected sedative-hypnotics (including benzodiazepines, muscle relaxants, and antidepressants) in nine participants. Among the sedative-hypnotic exposed, fentanyl concentrations were lower, but naloxone dosing was similar to those without a concomitant exposure. CONCLUSIONS: In this study, we found that: 1) fentanyl was present in the blood of nearly all participants; 2) fentanyl concentrations were lower among study participants with concomitant sedative-hypnotic exposure; and 3) the dose of naloxone administered for overdose reversal was not associated with the measured fentanyl concentration in blood specimens. Our results underscore the role that tolerance and concomitant drug exposure play in the precipitation and resuscitation of management of opioid overdose.

Factors Associated with Lack of HIV Testing among Latino Immigrant and Black Patients at 4 Geographically and Demographically Diverse Emergency Departments.

The need for HIV testing in US emergency departments (EDs) has not been assessed, particularly among Latino immigrants and Blacks. We surveyed Latino immigrant and Black 18 to 64-year-old patients at 4 EDs about demographic characteristics, HIV testing history, and health literacy. A subset of patients was further surveyed on HIV risk-taking behaviors. Of the 2,265 participants, 24% had never been tested for HIV. Latino immigrants were more likely than Blacks never to have been tested for HIV (28% vs. 16%). In multivariable logistic regression, for Latino immigrants, male gender and lower health literacy were associated with no previous HIV testing. Among the 1,141-participant subset providing HIV risk-taking behavior data, 23% reported at least one risk factor and of those with at least one risk factor, 23% had never been tested for HIV. There remains a need for HIV testing among adult Latino immigrant and Black patients in US EDs.

Comparison of a video to a pictorial brochure in improving HIV/AIDS and HIV testing knowledge and increasing HIV testing motivation and behavioral skills among adult emergency department patients.

OBJECTIVES: We sought to determine if a pictorial brochure improves HIV/AIDS and HIV testing knowledge and increases HIV testing motivation and behavioral skills as well as a video among adult emergency department patients, regardless of language spoken and health literacy level. METHODS: ED patients were stratified by primary language spoken (English or Spanish) and health literacy level (lower or higher) and randomly assigned to watch the study video or review the content-matched pictorial brochure. HIV/AIDS and HIV testing knowledge, motivation for HIV testing, and behavioral skills for HIV testing were assessed using study instruments before and after watching the video or reviewing the pictorial brochure. RESULTS: Of the 712 English- and 655 Spanish-speaking ED patients, HIV/AIDS and HIV testing knowledge improved more among participants in the video than the pictorial brochure arm (∆ 0.43; 95% confidence interval [CI]: 0.07, 0.79). This improvement was more pronounced among those with lower (∆ 0.60; 95% CI: 0.06, 1.13) than higher health literacy (∆ 0.27; 95% CI: -0.22, 0.76). HIV testing motivation was high before the intervention and did not increase differentially between arms. Confidence in recognizing when to be tested for HIV was slightly greater in the video than pictorial brochure arm (∆ 0.15; 95% CI: 0.01, 0.28), but did not differ by language spoken or health literacy level. CONCLUSIONS: A video improved HIV/AIDS and HIV testing knowledge slightly more than a pictorial brochure. Other considerations (eg, patient volume, staffing, space, and video access) should guide EDs on how best to provide information about HIV testing to ED patients.

Evaluation of an advanced practice provider emergency department critical care step-down unit.

OBJECTIVE: In response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider-staffed critical care step-down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations. METHODS: We compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre-CCSU period). RESULTS: There were 31,418 critical care ED patient visits in the pre-CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre-CCSU period (∆1 [95% confidence interval (CI) = -2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆-4 [95% CI = -7.8, -0.2] minutes). 72-hour return ED visits also did not change overall (∆0% [95% CI = -0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = -0.05, -0.4]). CPT E&M billing increased for highest-level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]). CONCLUSION: This ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72-hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider-staffed solution to improvement in critical care in ED.

Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults. METHODS: The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians. RESULTS: Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed. CONCLUSION: Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.

Factors Associated with the Discordance between Perception of Being HIV Infected and HIV Sexual Risk Taking among Social Media-Using Black, Hispanic, and White Young Men Who Have Sex with Men.

Among HIV-uninfected, social media-using black, Hispanic, and white young men who have sex with men (YMSM) who had condomless anal sex but had not been HIV tested within the past year, we aimed to determine the extent of discordance between perception of having an undiagnosed HIV infection and HIV risk-taking behaviors. Despite reporting condomless anal sex without HIV testing, 64% of 358 YMSM participants perceived having an undiagnosed HIV infection as "unlikely" and 12% as "impossible." Having a primary care provider and being Hispanic were associated with greater discordance. Interventions to decrease the discordance between perceived and actual HIV risk are needed for this higher HIV risk population.

Limited Ability of Three Health Literacy Screening Items to Identify Adult English- and Spanish-Speaking Emergency Department Patients With Lower Health Literacy.

STUDY OBJECTIVE: Brief, easily administered, and valid health literacy assessment tools are needed to optimize health care delivery in the emergency medicine setting. Three health literacy screening items have been proposed to assess health literacy in outpatient settings. We investigated their ability to identify English- and Spanish-speaking adult emergency department (ED) patients with lower health literacy. METHODS: Participants were Spanish- or English-speaking adult patients randomly selected from 4 geographically spread, US, urban, safety-net EDs. Participants completed the 3 health literacy screening items, as well as the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E). Test performance characteristics, including receiver operating characteristics area under the curve, of the 3 health literacy screening items were estimated, as compared with the SAHL-S&E. RESULTS: According to the SAHL-S&E, 36% of the 1,165 English speakers and 35% of the 1,605 Spanish speakers had lower health literacy. Areas under the curve for each health literacy screening item individually were: needing others to help read materials (English 0.59, 95% confidence interval [CI] 0.56 to 0.62; Spanish 0.58, 95% CI 0.56 to 0.61), problems learning because of difficulty reading (English 0.63, 95% CI 0.60 to 0.66; Spanish 0.59, 95% CI 0.56 to 0.62), and confidence with completing forms (English 0.62, 95% CI 0.59 to 0.65; Spanish 0.60, 95% CI 0.57 to 0.63). Areas under the curve for the 3 screening items combined were: English 0.66 (95% CI 0.63 to 0.70) and Spanish 0.62 (95% CI 0.59 to 0.64). CONCLUSION: The 3 health literacy screening items performed poorly in identifying adult ED patients with lower health literacy. Higher-validity screening measures are needed to better serve the health care needs of this vulnerable population in the ED setting.

GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data.

OBJECTIVES: We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation. DESIGN: Single-blind randomized controlled pilot study. SETTING: Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall. INTERVENTION: Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT). MEASUREMENTS: We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention. RESULTS: Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult. CONCLUSION: These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019.

A Retrospective Analysis of Nursing Home to ED Transfer Correspondence Length and ED Length of Stay.

OBJECTIVES: To describe a) the length of nursing home (NH) to emergency department (ED) transfer correspondences and b) determine the relationship between NH-ED transfer correspondence length and ED length of stay (LOS). METHODS: This is a secondary analysis of a retrospective cohort study that examined the health records of NH patients who visited one of three Rhode Island EDs included in the study. We used descriptive statistics to examine correspondence length and ED LOS and median quantile regression to evaluate the association between correspondence length and ED LOS. RESULTS: Of the 456 ED visits, the median correspondence length was 12 pages (25th, 75th percentile: 8.5, 17 pages). For every one-page increase in correspondence length, the median ED LOS was not significantly changed (Coefficient: 0.82 minutes, 95% CI: -0.56, 2.19). CONCLUSIONS: While correspondence length was not associated with ED LOS, this study suggests that stakeholders should work to decrease documentation burden.

GAPcare: the Geriatric Acute and Post-acute Fall Prevention Intervention-a pilot investigation of an emergency department-based fall prevention program for community-dwelling older adults.

BACKGROUND: Falls are the leading cause of fatal and non-fatal injuries among older adults. Older emergency department (ED) patients who present for evaluations after falls have a 30% higher risk of falling again in the subsequent 6 months than age-matched controls. Although EDs frequently evaluate older adults after their falls, the typical evaluation consists of an injury assessment alone. As such, an opportunity is lost to assess and address the potential causes of falls in this vulnerable population. In this manuscript, we present a multidisciplinary fall prevention protocol for a pilot study of older adult ED patients who recently sustained a fall (GAPcare: the Geriatric Acute and Post-acute Fall Prevention Intervention). METHODS: GAPcare is a randomized single-blinded pilot study. Participants in GAPcare are 120 older adults (≥ 65 years old) who present to 1 of 2 academic US EDs after a fall. We randomly assign participants 1:1 to an intervention or a usual care (control) arm. In the intervention arm, the patient's ED physician, a pharmacist, and a physical therapist (PT) collaborate to identify and address any risk factors that may have contributed to the fall. Intervention arm participants and their caregivers return home with a medication-related action plan to taper or stop potentially inappropriate medications and to address polypharmacy and a PT assessment and plan. Participants in the usual care arm receive standard assessments and care in the ED and a home safety brochure. Participants in both study arms complete fall calendars for 6 months to document the number of falls and healthcare visits during follow-up. The primary outcome is feasibility of the GAPcare fall prevention intervention (number and proportion of screened participants who are eligible, recruited, and retained; impact on ED length of stay), while the secondary outcome is to estimate its initial efficacy. DISCUSSION: The GAPcare-ED fall prevention intervention has the potential to promote older adult-sensitive care for millions of Americans presenting to EDs after falls and establish a protocol for a future large-scale randomized controlled trial on this topic. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03360305. Trial registration date: December 4, 2017. Protocol version: 1.

Emergency Department-Provided Home Blood Pressure Devices Can Help Detect Undiagnosed Hypertension.

INTRODUCTION: Emergency departments (EDs) are critical sites for hypertension (HTN) screening. Home blood pressure (BP) monitoring (HBPM) is used routinely in outpatient settings, yet its utility after the ED visit for those with elevated BP in the ED is unclear. AIM: In this pilot study, we assessed if HBPM could detect HTN in patients with elevated in-ED BP. METHODS: From September 2014 to July 2017, we recruited adult patients at an urban, academic ED with a triage BP ≥ 120/80 mmHg and no history of HTN into this prospective cohort observational study. After their ED visit, participants obtained BP measurements for two weeks using a validated HBPM. HTN was considered probable if the average HBPM BP was ≥ 135/85 mmHg. We calculated the proportion of participants whose ED BP measurement accurately predicted HTN using HBPM after discharge. RESULTS: Of 136 participants enrolled, 93 (68%) returned the HBPM with at least four home BP measurements [mean number of measurements obtained: 29 (SD: 17, range 4-59)]. Participants' median age was 40 years-old (IQR 34-48); 55% were female, 19% were black, and 58% were white. Forty-six percent of participants with elevated in-ED BP had HTN in follow-up. CONCLUSIONS: For patients with elevated BP in the ED, HBPM could be valuable for determining which patients have HTN and require expedient follow-up.

The Impact of Incomplete Nursing Home Transfer Documentation on Emergency Department Care.

OBJECTIVES: Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission. DESIGN: Retrospective study using 2 abstractors blinded to the study aims. SETTING AND PARTICIPANTS: 474 records from NH residents transferred to the 3 EDs of Rhode Island's largest health care system from September 2015 to September 2016. MEASURES: NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission. RESULTS: Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P = .03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01-1.18). CONCLUSIONS/IMPLICATIONS: Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms.

National trends in the emergency department management of adult patients with elevated blood pressure from 2005 to 2015.

Emergency department (ED)-based screening and referral of patients with elevated blood pressure (BP) are recommended by 2006 and 2013 American College of Emergency Physicians guidelines; however, it is unknown if these recommendations or disparities in care impact clinical practice. The objectives of the study were to assess temporal trends in antihypertensive prescriptions, outpatient follow-up referrals, and diagnosis of hypertension (HTN)/elevated BP and to identify potential disparities by patient characteristics. Using the 2005-2015 National Hospital Ambulatory Medical Care Survey, we examined the frequency and trends over time of antihypertensive prescriptions, outpatient follow-up referrals, and BP diagnoses for US ED visits by adult patients with an elevated triage BP and identified potential disparities in management by patient demography and socioeconomic status. Of the 594 million eligible ED visits by patients from 2005 to 2015, 1.2% (1.0%-1.4%) received antihypertensive prescriptions at discharge, 82.3% (80.0%-83.6%) outpatient follow-up referrals, and 2.1% (1.9%-2.4%) an HTN/elevated BP diagnosis. There were small annual increases over time in the odds of antihypertensive prescriptions at discharge (adjusted odds ratio [aOR] 1.05 [1.00-1.10]), follow-up referrals (aOR 1.04 [1.01-1.07]), and HTN/elevated BP diagnosis (aOR 1.05 [1.02-1.08]). For BPs ≥160/100 mm Hg, prescriptions were more common for Blacks (aOR 2.36 [1.93, 2.88]) and uninsured patients (aOR 1.81 [1.38, 2.38]), and diagnoses were more common for Blacks (aOR 1.95 [1.70, 2.24]) and uninsured patients (aOR 1.30 [1.09, 1.55]). These data suggest little change in and the need for improvement in the management of ED patients with elevated BP, despite the American College of Emergency Physicians guidelines, and raise concern about patient care disparities.

A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications.

BACKGROUND: The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation-related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre-oxygenation modalities increased first-pass intubation success and reduced intubation-related complications. METHODS: A prospective pre/post-comparison of a modified Montpellier protocol in two medical and one medical/surgical/cardiac ICU within a hospital system. The modified eight-point protocol included: fluid administration, ordering sedation, two intubation trained providers, pre-oxygenation with non-invasive positive pressure ventilation, nasal high flow cannula or non-rebreather mask, rapid sequence intubation, capnography, sedation administration, and vasopressors for shock. RESULTS: Patient characteristics and indications for intubation were similar for the 275 intubations in the control (137) and intervention (138) periods. In the intervention vs. control periods, the modified Montpellier protocol was associated with a significant 16.2% [95% CI: 5.1-30.0%] increase in first-pass intubation success and a 12.6% [95% CI: 1.2-23.6%] reduction in all intubation-related complications. CONCLUSION: A simplified version of the Montpellier intubation protocol for intubating ICU patients was associated with an improvement in first-pass intubation success rates and a reduction in the rate of intubation-related complications.