Risk Factors and Emergency Department Outcomes in Methamphetamine-Associated Cardiomyopathy: A Case-Control Study.

BACKGROUND: Methamphetamine-associated cardiomyopathy (MACM) is a known complication of methamphetamine use; however, risk factors and outcomes of patients with MACM are not well understood. STUDY OBJECTIVES: This study aims to identify risk factors, emergency department (ED) interventions, and outcomes for MACM. METHODS: This case-control study was conducted between 2012 and 2020 at two academic EDs. ED patients ≥18 years with an index visit that included documented methamphetamine use were included. Patients with documented MACM during follow-up (3 months-3 years) were considered cases (MACM). A control group comprised of patients with documented methamphetamine use but no known MACM was matched at a 2:1 ratio. Logistic regression was used to model risk factors for MACM. RESULTS: A total of 9833 patients with methamphetamine use were identified. From this, 160 MACM patients were matched to 322 controls. The mean age was 48.4 years, and 143 patients (29.7%) were female. MACM patients were more likely to be admitted on their index visit (45.6% vs. 34.8%, p = 0.021). Significant variables associated with MACM included: admission at the index visit (odds ratio [OR] 1.51), diabetes (OR 3.02), kidney disease (OR 5.47), and pulmonary disease (OR 2.39). MACM patients had more ED visits in the follow-up period (10.1 vs. 7, p = 0.009) and were admitted at a higher rate across all visits (32.5% vs. 15.4%, p = 0.009). Additionally, MACM patients had significantly longer hospital stays than controls (mean 18 additional days, p = 0.009). CONCLUSION: Patients who developed MACM had traditional risk factors for heart failure and experienced significantly more ED visits, more hospitalizations, and longer hospital stays than matched controls.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty.

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES: We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS: POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS: In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS: We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.

Factors Associated With Geriatric Frequent Users of Emergency Departments.

STUDY OBJECTIVE: Frequent users of the emergency department (ED) are often associated with increased health care costs. Limited research is devoted to frequent ED use within the increasing senior population, which accounts for the highest use of health care resources. We evaluate patient characteristics and patterns of ED use among geriatric patients. METHODS: This was a multicenter, retrospective, longitudinal, cohort study of ED visits among geriatric patients older than 65 years in 2013 and 2014. Logistic regression analysis was used to identify independent associations with frequent users. The setting was a nonpublic statewide database in California, which includes 326 licensed nonfederal hospitals. We included all geriatric patients within the database who were older than 65 years and had an ED visit in 2014, for a total of 1,259,809 patients with 2,792,219 total ED visits. The main outcome was frequent users, defined as having greater than or equal to 6 ED visits in a 1-year period, starting from their last visit in 2014. RESULTS: Overall, 5.7% of geriatric patients (n=71,449) were identified as frequent users of the ED. They accounted for 21.2% (n=592,407) of all ED visits. The associations of frequent ED use with the largest magnitude were patients with an injury-related visit (odds ratio 3.8; 95% confidence interval 3.8 to 3.9), primary diagnosis of pain (odds ratio 5.5; 95% confidence interval 5.4 to 5.6), and comorbidity index score greater than or equal to 3 (odds ratio 7.2; 95% confidence interval 7.0 to 7.5). CONCLUSION: Geriatric frequent users are likely to have comorbid conditions and be treated for conditions related to pain and injuries. These findings provide evidence to guide future interventions to address these needs that could potentially decrease frequent ED use among geriatric patients.

Characterizing pediatric high frequency users of California emergency departments.

OBJECTIVE: Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users. METHODS: This was a retrospective multi-facility study of ED visits by children 1-17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1-5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users. RESULTS: There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred. CONCLUSIONS: The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.

The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism.

We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli). Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer. Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE. In our cohort, a DAGMAR Score < 2 equated to overall PE risk < 1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results. By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.

Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis.

BACKGROUND: Past studies suggest that patients who leave without being seen (LWBS) by a physician from a hospital's emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States. OBJECTIVE: This study describes the LWBS population at a multi-hospital academic health system. METHODS: This was a retrospective study of electronic medical record data from EDs at two academic hospitals with a shared patient population that analyzed all LWBS visits during the 45-month period between July 2012 and March 2016. Demographic and clinical variables, including patient characteristics, chief complaint, acuity, and evidence of ongoing medical care, were assessed. RESULTS: During the study period, 2.4% of patients presenting to the study EDs left without being seen. This population tended to have lower-acuity chief complaints and nearly triple the number of ED visits as the general ED patient; 7.8% sought follow-up care from outpatient clinics and 24.8% returned to the ED within 7 days. Of this latter group, 11.5% were subsequently admitted for inpatient care, representing 0.068% of the total ED census during the study period. CONCLUSIONS: LWBS patients are high ED utilizers who may be effectively targeted by "hotspotting." Our 11.5% admission rate at return after LWBS compares favorably with the overall 20.9% admission rate at the study EDs and represents a small minority of all LWBS visits. Given the paucity of return ED visits after interval clinic encounters, our data suggest that patients who were seen in clinic had their medical complaint adequately resolved on a non-emergent outpatient basis, and that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED.

Screening Tools Validated in the Outpatient Pain Management Setting Poorly Predict Opioid Misuse in the Emergency Department: A Pilot Study.

BACKGROUND: Currently, no universally accepted methods exist to assess drug-related aberrant behaviors in emergency department (ED) patients. There are several screening tools to identify opioid misuse in patients with chronic pain, however, the validity of these screening tools to assess for misuse within the ED remains unclear. OBJECTIVES: This study investigated the effectiveness of three commonly used screening tools, previously validated in outpatient pain management settings, to assess risk of opioid misuse in ED patients. METHODS: This was a prospective observational study of 154 participants (median age 50 years; 49.6% female) presenting to an academic ED for a chief complaint of pain ≥ 6 months or an opioid refill request. Participants completed the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the Current Opioid Misuse Measure. Scores for each were compared with electronic medical record (EMR) data alone or a reference standard comprising EMR + statewide prescription drug monitoring program (PDMP) + medical examiner database. RESULTS: Using the combined reference standard, 55.8% of participants displayed at least one aberrant behavior. Regardless of the reference standard, the test characteristics of these screening tools were modest at best, with likelihood ratios close to 1. CONCLUSION: Three screening tools previously validated in outpatient pain management settings poorly categorized risk among ED patients with chronic noncancer pain or requests for opioid refills, and should not be used to assess drug-aberrant behaviors in the ED. Review of the EMR alone or together with the PDMP may be more useful methods to assess drug-aberrant behaviors in the ED setting.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department.

BACKGROUND: Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients. METHODS: This prospective observational study enrolled a convenience sample of patients who answered "yes" to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated. RESULTS: 276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66-0.73). CONCLUSION: Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge.

BACKGROUND: Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction. OBJECTIVE: The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction. METHODS: Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ2 test. RESULTS: Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ2 = 4.57, degrees of freedom [df] = 2, p = 0.10; χ2 = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ2 = 2.88, df = 2, p = 0.24). CONCLUSIONS: Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.

A Description of a Health System's Emergency Department Patients Who Were Part of a Large Hepatitis A Outbreak.

BACKGROUND: A recent hepatitis A virus (HAV) outbreak in San Diego, California represents one of the largest HAV outbreaks in the United States. The County of San Diego Health and Human Services Agency identified homelessness and illicit or injection drug use as risk factors for contracting HAV during this outbreak. OBJECTIVE: We describe those patients who presented to our Emergency Department (ED) and were identified as HAV positive. METHODS: This was a retrospective descriptive study conducted at a tertiary care university health system's EDs from November 2016 to February 2018. Included were those of all ages who tested positive for HAV immunoglobulin M antibody. Outcome measures included: 1) demographic data; 2) number of patients testing positive for HAV by week and month of the outbreak; 3) homeless status, illicit and injection drug use, and alcohol use; 4) ED chief complaint; 5) initial liver function and coagulopathy test results, hepatitis B and C test results, and initial vital signs; 6) admission status; 7) death; and 8) the 7-day ED revisit rate for nonadmitted patients and the 30-day all-cause readmission rate for admitted patients. RESULTS: We identified 57,721 patients with at least one ED visit, and 1,453 of these were tested for HAV; 133 patients (9.2%) tested positive. Average age was 45.1 years, and 91 (68.4%) were male. Eighty-six patients (64.7%) were homeless and 53 patients (39.8%) reported illicit or injection drug use; 64 patients (48.1%) had chief complaints consistent with typical HAV symptoms. Most patients (112 or 84.2%) were admitted. Nine patients (6.8%) were admitted to a critical care setting; 8 patients (6%) died. CONCLUSIONS: During this large HAV outbreak, 9% of those screened for HAV tested positive. The majority were homeless, and 40% reported illicit or injection drug use. Most required hospitalization, and 6% of patients died.