Impact of a trauma recovery center on emergency department utilization for victims of violence.

BACKGROUND: Victims of violence are at high risk for unmet mental and physical health care needs which can translate into increased Emergency Department (ED) visits. We investigated the effectiveness of participation in a psychosocial, case management-based trauma recovery program on ED utilization. METHODS: A retrospective cohort study of ED utilization before and after referral to a Trauma Recovery Center (TRC). Charts of TRC participants from 6/2017-5/2019 who consented in clinic to their medical records being used for research were reviewed. The primary outcome was the change in ED utilization 6 months pre- and post-referral to a TRC. The secondary outcomes were factors associated with ED visits after TRC referral, including victimization or mental health issues. RESULTS: The study group contained 143 patients, of which 82% identified as female and 62% identified as white. Many (39%, n = 56) were part of one or more vulnerable populations and type of victimization varied extensively. Intervention uptake was high as almost all (92%, n = 132) had at least one TRC encounter [median of 6 encounters (IQR 2-13)] and an average of 2.7 services used. Most participants (67.1%, n = 96) had no change in ED use. Forty (28.0%) had at least 1 ED visit 6 months before, 38 (26.8%) had at least 1 ED visit 6 months afterwards, and 81 (56.6%) had no ED visits during either timeframe. ED visits per person in the 6 months prior to referral were not different from visits per person in the 6 months after referral (0.52 vs 0.49, p = 0.76, paired t-test). Negative binomial regression indicated number of ED visits before referral (IRR 1.5, 95% confidence interval [1.27-1.79]) and pre-existing mental health conditions (IRR 2.2, 95% confidence interval [0.98-5.02]) were most associated with an increase in the incidence rate ratio of ED visits in the 6 months after referral. CONCLUSION: Despite high engagement, a multidisciplinary Trauma Recovery Center did not reduce ED utilization. ED utilization prior to TRC was the most predictive factor of ED utilization afterwards.

Preoperative levels of urinary uromodulin predict acute kidney injury after pediatric cardiopulmonary bypass surgery.

BACKGROUND: Acute kidney injury (AKI) is a common complication of cardiopulmonary bypass surgery (CPB) in children. Several promising postoperative AKI biomarkers have been identified, but no preoperative biomarkers are available. We evaluated the association of urinary uromodulin (uUMOD) with postoperative AKI. METHODS: One hundred and one children undergoing CPB were enrolled. Urine was collected prior to CPB, and AKI was defined as ≧50% increase in serum creatinine from preoperative baseline within 48 h of surgery. RESULTS: Forty-seven patients (47%) developed AKI, and 92% of participants in the lowest quartile of preoperative uUMOD concentrations developed AKI compared with 8% in the highest quartile. Patients with preoperative uUMOD levels in the lowest quartile had 132.3× increased risk of postoperative AKI versus the highest quartile. Raw uUMOD levels were significantly lower in patients with AKI vs. no AKI. Significance was unchanged after correcting uUMOD levels for urinary creatinine. Receiver operating characteristic analysis showed preoperative uUMOD strongly predicted postoperative AKI, with area under the curve (AUC) 0.90. Stepwise logistic regression analysis revealed a model combining uUMOD, and bypass time predicted AKI at p<0.001. Neither Risk Adjustment for Congenital Heart Surgery 1 (RACHS) score nor age improved the model's ability to predict AKI. Independent analysis demonstrated that while bypass time was associated with AKI, the predictive ability of bypass time (AUC 0.77) was less than that of preoperative uUMOD levels (AUC 0.9). CONCLUSIONS: Children with lowest preoperative levels of uUMOD have greatly increased risk of AKI post-CPB. If uUMOD were used to risk-stratify patients undergoing CPB, clinical measures could be taken to minimize AKI development.

Subclinical Kidney Injury in Children Receiving Nonsteroidal Anti-Inflammatory Drugs After Cardiac Surgery.

OBJECTIVE: To investigate the association of nonsteroidal anti-inflammatory drug (NSAID) administration with urinary neutrophil gelatinase-associated lipocalin (NGAL) levels in children following cardiopulmonary bypass (CPB) who did not develop acute kidney injury (AKI). STUDY DESIGN: In this prospective observational study, urinary NGAL levels were investigated in 210 children who underwent cardiothoracic surgery requiring CPB. Children with clinical AKI (defined as an increase in serum creatinine ≥50% from baseline within 72 hours of CPB) were excluded from the analysis. NSAIDs were administered no sooner than 24 hours after CPB. NGAL levels were compared between children who received NSAIDs (n = 146) and those who did not receive NSAIDs (n = 64). RESULTS: The median age was 3.2 years in the children who received NSAIDs and 2.5 years in those who did not receive NSAIDs (P = .05). Before NSAID administration at 24 hours following CPB, the median NGAL level was 15 ng/mL in both groups (P = .92). Following NSAID administration, the median urinary NGAL level increased to 83 ng/mL (IQR, 45-95 ng/mL) at 72 hours after CPB in those receiving NSAIDs (P < .001). In contrast, the median NGAL level decreased to 10 ng/mL (IQR, 5.4-15.9 ng/mL) at 72 hours after CPB in those who did not receive NSAIDs (P = .01). In multivariable analysis, children receiving NSAIDs demonstrated a 5-fold elevation of urinary NGAL levels at 60-72 hours following CPB compared with those who did not receive NSAIDs (P < .001). CONCLUSION: NSAID administration was associated with a significant increase in urinary NGAL in children who did not develop clinical AKI following CPB. This indicates that NGAL can detect NSAID-induced subclinical kidney injury in this population.

Locating Advance Care Planning Documents in the Electronic Health Record during Emergency Care.

CONTEXT: Emergency Departments (EDs) care for people at critical junctures in their illness trajectories, but Advanced Care Planning (ACP) seldom happens during ED visits. One barrier to incorporating patient goals into ED care may be locating ACP documents in the electronic health record (EHR). OBJECTIVES: To determine the ease and accuracy of locating ACP documentation in the EHR during an ED visit. METHODS: Academic ED with 82,000 visits per year. The EHR system includes a Storyboard with the patient's code status and a link to ACP documents. A real-time chart audit study was performed of ED patients who were either ≥65 years old or had a cancer diagnosis. Data elements included age, Emergency Severity Index, ACP document location(s) in the EHR, Storyboard accuracy, ED code status orders, and discussions of ACP or code status. RESULTS: Of the 160 audited charts, 51 (32%) were for adults <65 years old with a cancer diagnosis. Code status was discussed and updated during the ED visit in 68% (n=108). ACP documents were found in 3 different EHR places. Only 30% (n=48) had ACP documents in the EHR, and of these (22%, n=13) were found in only one of the three EHR locations. The Storyboard was inaccurate for 5% (n=8). ED case managers frequently discussed APC documentation (78%, 43/55 charts). CONCLUSIONS: Even under optimal conditions with social work availability, ACP documents are lacking for ED patients. Multiple potential locations of ACP documents and inaccurate linkage to the Storyboard are potentially addressable barriers to ACP conversations.