Emergency Department Co-testing for Human Immunodeficiency Virus When Testing for Gonorrhea and Chlamydia: A Readily Available, Missed Opportunity for Targeted HIV Testing in Emergency Departments

OBJECTIVES

Conducting human immunodeficiency virus (HIV) testing in emergency departments (EDs) can be an effective approach to testing and reaching populations at highest risk of contracting HIV.

METHODS

All gonorrhea and chlamydia (G/C) and HIV tests ordered in the Cleveland Clinic Health System's 14 EDs were included in the analysis. Data were collected from electronic health records. Descriptive statistics, with medians and means, were computed.

RESULTS

From January 1, 2019, to December 31, 2021, we reviewed ED visits for the purpose of sexually transmitted infection (STI) screening, with an emphasis on G/C screening. In October 2019, both HIV rapid testing and G/C testing began across all 14 Cleveland Clinic EDs. The overall rate of co-testing for HIV when obtaining a G/C test for STI evaluation increased overall to around 30% for our health system EDs, with some individual EDs approaching 60%.

CONCLUSIONS

The approach the Cleveland Clinic implemented is an effective way to test for HIV in the ED. Local health departments and stakeholders in HIV communities should support and collaborate with EDs in their jurisdictions to accelerate HIV testing initiatives by using an HIV plus G/C co-testing metric.

Evaluation of missed influenza vaccination opportunities in the emergency department

BACKGROUND

Seasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018-2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data.

METHODS

This was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 - April 30) over a two-years, 2018-2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity.

RESULTS

A total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions.

CONCLUSION

Patients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis

OBJECTIVES

To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache.

BACKGROUND

Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization.

METHODS

This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated.

RESULTS

Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase.

CONCLUSION

Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

Disparities in prostate cancer diagnoses in persons experiencing homelessness

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Background: We previously reported that persons experiencing homelessness (PEH) are significantly less likely to undergo prostate specific antigen (PSA) testing compared to persons not experiencing homelessness (non-PEH). The purpose of this study was to determine if reduced PSA testing in PEH results in more advanced prostate cancer diagnoses. Methods: We identified PSA screening eligible PEH (men ages 50-69) from an institutional registry of all patients that presented to our healthcare system as homeless from 2014 to 2021. A matched cohort of non-PEH was generated for comparison. Institutional CPT and HCPCS billing codes for PSA testing were available beginning 01/01/2017 and cross-referenced to identify PEH and non-PEH who underwent PSA testing at least once between 01/01/2017 and 12/31/2021. In patients with ≥ 1 PSA test, we recorded screening, oncologic and treatment related variables. Patients with a history of prostate cancer diagnosed outside the study timeframe were excluded. Results: A total of 9,249 PEH were identified, with 1,597 meeting PSA screening criteria during the study timeframe; 3,370 screening eligible non-PEH were available for comparison. The median age was 59.0 for PEH and 60.0 for non-PEH. PEH were significantly less likely to have a primary care provider (58% vs 81%, p<0.001) or to have a PSA test (12% vs 33%, p<0.001). Among patients with a PSA test, PEH were significantly less likely to have multiple PSA tests compared to non-PEH (28% vs 61%, p<0.001) and significantly more likely to have a PSA ≥ 4.0 (18% vs 12%, p=0.028). In patients with a PSA ≥ 4.0, PEH were less likely to receive a prostate biopsy (37% vs 61%, p =0.009) and there was a trend towards decreased prostate MRI (11% vs 25%, p=0.085). A total of 6 PEH (0.4%) and 46 non-PEH (1.4%) were diagnosed with prostate cancer. The median PSA at diagnosis was 12.6 in PEH vs 7.0 in non-PEH (p=0.052). PEH were significantly more likely to present with high/very high risk disease (4/6 [66%] vs 9/46 [20%], p=0.019); no PEH had very low/low risk disease compared with 20 (43.5%) non-PEH. PEH were more likely to present with lymph node positive or metastatic disease (3/6 [50%] vs 3/46 [7%], p=0.016). The median time from biopsy to treatment was 119 days in PEH and 76 days in non-PEH (p=0.391). Conclusions: PEH are less likely to receive prostate cancer testing following an elevated PSA and more likely to present with high risk advanced prostate cancer. Interventions to increase prostate cancer awareness in PEH are needed to reduce disparities.

Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness

PURPOSE

Persons experiencing homelessness (PEH) have low rates of cancer screening and worse cancer mortality compared with persons not experiencing homelessness. Data regarding cancer diagnosis and treatment in PEH are limited. We investigated cancer prevalence and use of radiation therapy (RT) in PEH.

METHODS AND MATERIALS

Patients presenting between January 1, 2014, and September 27, 2021, at a large metropolitan hospital system were assessed for homelessness via intake screening or chart search. PEH data were cross-referenced with the institution's cancer database to identify PEH with cancer diagnoses. Demographic, clinical, and treatment variables were abstracted.

RESULTS

Of a total of 9654 (9250 evaluable) PEH with a median age of 42 years, 81 patients (0.88%) had at least 1 cancer diagnosis and 5 had multiple diagnoses, for a total of 87 PEH with at least 1 cancer diagnosis. The median age at diagnosis was 60 years. In total, 43% were female and 51% were Black, and 43% presented with advanced or metastatic disease. Lung (17%), prostate (15%), leukemia/lymphoma (13%), and head/neck (9%) were the most common diagnoses. In total, 17% of patients underwent surgery alone, 13% received chemotherapy alone, 14% received RT alone, and 6% received hormone therapy alone. A total of 8% of patients underwent no treatment, and 43% underwent multimodality therapy. In total, 58% of treated patients never achieved disease-free status. Of the 31 patients who received RT, 87% received external beam RT. Most patients (70%) received hypofractionated regimens. For patients who had multifraction treatment, the treatment completion rate was 85%, significantly lower than the departmental completion rate of 98% (P < .00001).

CONCLUSIONS

In a large cohort of PEH in a metropolitan setting, cancer diagnoses were uncommon and were frequently in advanced stages. Most patients underwent single-modality treatment or no treatment at all. Despite the use of hypofractionation, the RT completion rate was low, likely reflecting complex barriers to care. Further interventions to optimize cancer diagnosis and treatment in PEH are urgently needed.

Antemortem Health System Utilization in People Experiencing Homelessness Who Died in the Emergency Department

People experiencing homelessness (PEH) have high rates of mortality, medical and psychiatric comorbidities, and emergency department utilization. In this study, a health system's emergency department encounters were evaluated to identify PEH who died in the emergency department. Patient demographics, medical history, prehospital and emergency department characteristics, and health care utilization patterns were collected. Descriptive statistics were calculated. We identified 48 PEH pronounced dead in the emergency department; mean age at death was 46.5. Forty-four (92%) decedents presented in cardiac arrest, 12 (25%) of which were substance use-related; 4 (8%) presented with trauma. Out of 44 patients presenting in cardiac arrest, (20.5%) had bystander cardiopulmonary resuscitation (CPR) performed before arrival of emergency medical services. In the year prior to death, 15 (32%) decedents had no documented health care utilization, while 16 (33%) had 10 or more emergency department/outpatient visits. Our study is the first to characterize PEH who died in the emergency department, analyzing the pre-hospital and in-hospital characteristics and antemortem health system utilization in this population. A sizeable proportion of deceased PEH had no health system contact in the 12 months prior to death, suggesting that those with high mortality risk may underutilize health services. Conversely, a similar proportion of decedents had extensive (more than 10) health system utilization in the year prior to death, representing possible opportunities to reduce mortality.

Cotesting for Human Immunodeficiency Virus and Sexually Transmitted Infections in the Emergency Department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) guidelines recommend screening for human immunodeficiency virus (HIV) in patients aged 15 to 65 years, as well as those at increased risk. Patients screened in the emergency department (ED) for gonorrhea (GC) and/or chlamydia represent an increased-risk population. Our aim was to assess compliance with CDC and USPSTF guidelines for HIV testing in a national sample of EDs.

METHODS

We examined data from the 2010 to 2018 Nationwide Emergency Department Sample, which can be used to create national estimates of ED care to query tests for GC, chlamydia, HIV, and syphilis testing. Weighted proportions and 95% confidence intervals (CIs) were reported, and Rao-Scott χ 2 tests were used.

RESULTS

We identified 13,443,831 (weighted n = 3,094,214) high-risk encounters in which GC/chlamydia testing was performed. HIV screening was performed in 3.9% (95% CI, 3.4-4.3) of such visits, and syphilis testing was performed in 2.9% (95% CI, 2.7-3.2). Only 1.5% of patients with increased risk encounters received both HIV and syphilis cotesting.

CONCLUSIONS

Despite CDC and USPSTF recommendations for HIV and syphilis screening in patients undergoing STI evaluation, only a small proportion of patients are being tested. Further studies exploring the barriers to HIV screening in patients undergoing STI assessment in the ED may help inform future projects aimed at increasing guidance compliance.

Breast cancer screening in persons experiencing homelessness

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Background: Persons experiencing homelessness (PEH) suffer from poor health outcomes, including worse cancer mortality, compared to persons not experiencing homelessness. A portion of the disparity in cancer outcomes is attributable to reduced access to cancer screening, leading to more advanced-stage disease and a higher risk of death compared to the general population. Data regarding cancer screening rates in PEH are scarce. We therefore sought to evaluate baseline rates of breast cancer screening in PEH. Methods: All patients presenting for care from January 1, 2014 onward at a hospital system spanning five counties in a populous Midwestern state were screened for homelessness. Homelessness was identified by two criteria: presence of the Z-code for homelessness (Z59) in the patient’s electronic medical record, and/or patient’s address on record listed as an address matching that of a regional homeless shelter, transitional housing, or “homeless.” Identified PEH were maintained in a prospective registry. For each female PEH in the screening age range, billing data for completed breast cancer screening mammography performed in the previous five years (1/1/17-12/31/21) were extracted (CPT codes 77063, 77067). Data were also extracted for a cohort of non-PEH patients eligible for screening. Demographic and clinical data were extracted for all patients. This study was approved by the hospital system’s IRB. Results: A total of 3,474 female (biological sex) PEH were identified, with 1,320 eligible for screening mammography (alive and between the ages of 40 and 79) in the study timeframe. The median age was 53.5 years old; 44% were Black, 48% White, 8.5% unknown/other race, and 3% Hispanic ethnicity. 28% of PEH were uninsured, and 67% had government insurance; 66% had an assigned primary care physician (PCP). Of PEH eligible for screening mammography, 237 (18%) had at least one screening mammogram during this five-year interval (2017, 2.2%; 2018, 4.3%; 2019, 3.6%; 2020, 3.7%; 2021, 4.3%). In a cohort of 6,240 non-PEH eligible for screening over the same timeframe, the screening mammography rate was 32%, which was significantly higher than the screening rate for PEH (p < 0.00001). Compared to PEH who did not undergo screening mammography, PEH who underwent screening mammography were more likely to have an assigned PCP (90% vs 38%, p < 0.00001), to be a non-current tobacco user (56% vs 35%, p < 0.00001), and to be a non-current illicit drug user (84 % vs 68%, p = 0.0015). PEH who underwent screening mammography were significantly less likely to be uninsured (12% vs 31%, p < 0.00001). Conclusions: In the largest study of its kind to date, we identified low rates of breast cancer screening in female PEH. Interventions to increase breast cancer screening in this vulnerable population are urgently needed and may include increased access to PCPs, tobacco and drug cessation programs, and provision of health insurance.

Sex-based differences in timely emergency department evaluations for patients with drug poisoning

OBJECTIVES

Unintentional poisoning was the leading cause of injury-related death in the United States in 2017. Prescribed and illicit drugs are the most common cause of poisoning, and timely management in the emergency department (ED) is important. Our aim was to identify any disparities in wait times associated with sex for drug poisoning-related ED visits.

STUDY DESIGN

We examined ED visits using data from the 2009-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS).

METHODS

Drug poisoning-related visits were identified using the International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification codes. Delayed assessment was defined as wait times exceeding the recommended triage time. Weighted logistic regression was used.

RESULTS

The average age was 36 years (standard error = 1.1), 54% female, 87% White and 29% had delayed assessment. Most common drugs were psychotropics (45%) and opioids (32%). Adjusting for race, payment source, urgency, multiple drug types and NSAIDs, females who had poisoning by substances other than opioids had 2.1 times higher likelihood of having a delayed assessment compared with males (odds ratio [95% confidence interval]: 2.1 [1.03-4.2]), although there was no difference between sexes among visits with opioid poisoning (P = 0.27). Neither race (P = 0.23) nor payment source (P = 0.22) were associated with delayed assessment, and the sex association was consistent across these groups.

CONCLUSIONS

Females with non-opioid drug poisoning were more likely to have delayed assessment than men. None of the other demographic factors demonstrated a correlation. Identifying more populations vulnerable to delays in the ED can help guide the development of interventions and policies to expedite care and attenuate existing disparities.

Seeing Red: Blood Sample Hemolysis Is Associated with Prolonged Emergency Department Throughput

INTRODUCTION

Hemolyzed emergency department (ED) blood specimens impose substantial burdens on various aspects of delivering care. The ED has the highest incidence of hemolysis among hospital departments. This study assessed the association and potential impact of hemolyzed blood samples on patient throughput time using ED length of stay (LOS) as the primary outcome measure.

METHODS

This study was a secondary analysis of data collected during a performance improvement project aimed at reducing the incidence of hemolysis in ED blood specimens. The electronic medical record was queried for potassium orders and results and for key patient throughput time points. Throughput times were stratified according to hemolysis, ED disposition (admitted vs discharged), and Emergency Services Index (ESI) triage categorization. Two-tailed t tests were used to compare throughput times for patients with and without hemolysis.

RESULTS

Potassium values were reported for 11 228 patient visits. The mean ED LOS was 287 minutes for patients with nonhemolyzed samples and 349 minutes for patients who had hemolyzed samples, a mean delay of 62 minutes. The mean throughput time for discharged patients was 92 minutes shorter in the group without hemolysis (337 vs 429 minutes). The mean throughput time for admitted patients was 28 minutes shorter in the group without hemolysis (264 vs 292 minutes). The increased LOS for patients with a hemolyzed blood sample was independent of the most commonly encountered ESI levels.

CONCLUSION

Hemolysis of blood samples obtained in the ED is associated with prolonged patient throughput via delays in patient disposition, independent of various markers of acuity, such as the patients' ultimate disposition or triage categorization.

The Hidden Cost of Hemolyzed Blood Samples in the Emergency Department

BACKGROUND

On average, patients with hemolyzed potassium samples spend about 1 h longer in the emergency department (ED), regardless of acuity level or disposition. We aimed to quantify the direct expenses associated with poor-quality preanalytic blood samples collected in the ED.

METHODS

We created a simple table with a range of direct expenses (i.e., costs) and rates of hemolyzed sample draws, allowing for identification of potential high-level cost-of-care impact analysis. We included a range of costs informed by review of literature on the topic. Those costs range from $600 to $3000 per bed-hour. This amount was inflation adjusted from 1996 to 2020 (1.68 × [direct cost per visit] × [100 000 visits per year/365 days/24 h]). We provided a range of hemolysis incidence based on previously reported data.

RESULTS

We showed that for an ED with 100 000 annual visits, a 40% draw rate for routine chemistries (including potassium), and a 10% hemolysis incidence, the direct cost impact of hemolysis waste is approximately $4 million/year as a result of the 1 h of added length of stay on average for a patient with a hemolyzed blood sample. This amount represents an annualized estimated cost of caring for a patient in the ED with an avoidable extended length of stay.

CONCLUSIONS

The financial burden of poor-quality blood samples can be estimated using cost per bed-hour and rate of sample failure. Similar methodology may identify additional QC issues with previously invisible financial implications.

Emergency Nurses' Knowledge, Attitudes, and Practices Related to Blood Sample Hemolysis Prevention: An Exploratory Descriptive Study

INTRODUCTION

The aim of the study was to identify emergency nurses' knowledge, attitudes, and practices related to blood sample hemolysis prevention and explore associations between these factors and demographic characteristics. The current state is unknown. Understanding baseline knowledge, attitudes, and practices addresses a gap in the literature.

METHOD

An exploratory, descriptive design with cross-sectional survey methodology employing a study-specific instrument was used.

RESULTS

Request for participation email was sent to a random sample of 5000 Emergency Nurses Association members, and 427 usable surveys were returned (response rate = 8.5%). Mean years in nursing was 13.85 (standard deviation = 10.78), and 226 (52.9%) were certified emergency nurses. Only 85 participants (19.9%) answered all 3 knowledge questions correctly. Answering the 3 knowledge questions correctly was significantly associated with being a certified emergency nurse (χ² = 7.15, P < .01). Participant responses to attitude items about the sequelae of blood sample hemolysis were skewed toward agreement, and most attitude items were associated with whom participants reported as being primarily responsible for phlebotomy. Emergency nurses remain primarily responsible for phlebotomy as well as addressing hemolyzed samples, but few reported that blood sample hemolysis was addressed at a departmental level.

DISCUSSION

Findings suggest that emergency nurses lack some knowledge related to blood sample hemolysis prevention best practices. Attitudes toward phlebotomy practices may be 1 reason practice has not changed. Every effort should be made to prevent hemolyzed blood samples to decrease delays and costs in emergency care.

Management of migraine in the emergency department: Findings from the 2010-2017 National Hospital Ambulatory Medical Care Surveys

OBJECTIVE

The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets.

METHODS

Using the 2010-2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic regression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor variables.

RESULTS

Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28% (95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years.

CONCLUSION

Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unnecessary opioids in the ED setting.

Ongoing and Focused Provider Performance Evaluations in Emergency Medicine: Current Practices and Modified Delphi to Guide Future Practice

The Joint Commission requires ongoing and focused provider performance evaluations (OPPEs/FPPEs). The authors aim to describe current approaches in emergency medicine (EM) and identify consensus-based best practice recommendations. An online survey was distributed to leaders in EM to gain insight into current practices. A modified Delphi approach was then used to develop consensus to recommend best practice. A variety of strategies are currently in use for OPPE/FPPE. “Peer reviewed cases with opportunity for improvement” was identified as a preferred metric for OPPE. Although the preference was for use of peer review in OPPE, a consistent and standard adoption of robust internal care review processes is needed to establish expected norms. National benchmarking is not available currently. This was a limited survey of self-identified leaders, and there is an opportunity for additional engagement of leaders in EM to identify a unified approach that appropriately relates to patient outcomes.

An intervention based on the Electronic Medical Record to improve smoking cessation guidance in an urban tertiary care center emergency department

INTRODUCTION

Smoking remains a major public health issue and a leading cause of death and disability in the United States. The objective of this study was to determine the effect of a simple intervention on smoking guidance, based on the electronic medical record (EMR), including providing discharge instructions and/or cessation counseling to emergency department (ED) patients who smoke.

METHODS

This was an interventional before-and-after study in an ED with 70000 visits per year. A pre-intervention and post-intervention chart review was performed on a random sample of ED visits occurring in 2014 and 2016, identifying smokers and the frequency with which smokers received discharge instructions and/or cessation counseling. In the fall of 2015, our EMR was programmed to deploy smoking cessation discharge instructions automatically.

RESULTS

In all, 28.7% (172/600; 95% CI: 25.2–32.4%) reported current smoking in the pre-intervention ED population and 27.6% (166/600; 95% CI: 24.2–31.4%) reported smoking in the post-intervention population. Smoking cessation guidance was provided to a total of 3.5% of self-reported smokers in the pre-intervention group (6/172; 95% CI: 1.4–7.6%); 1.2% (2/172; 95% CI: 0.3–4.1%) were informed of smoking cessation resources as part of their printed ED discharge instructions and 2.3% (4/172; 95% CI: 0.9–5.8%) received smoking cessation counseling by the ED provider. There was a statistically significant increase in the proportion of patients receiving any smoking cessation guidance after the intervention. All patients (166/166; 95% CI: 97–100% in this period received ED discharge instructions and a list of smoking cessation resources and 3.6% of smokers (6/166; 95% CI: 1.7–7.7%) received smoking cessation counseling by the ED provider.

CONCLUSIONS

Automated deployment of smoking cessation discharge instructions in the EMR improves smoking cessation discharge instructions, and also has a positive impact on improving rates of in-person counseling by ED providers.

Impact of Interventions to Change CBC and Differential Ordering Patterns in the Emergency Department

Objectives

A CBC with leukocyte differential (CBC-DIFF) is a frequently ordered emergency department (ED) test. The DIFF component often does not add to clinical decision making. Our objective was to evaluate the impact of a performance improvement project on CBC ordering.

Methods

ED orders for CBC-DIFF were identified through the laboratory information system. Two interventions were evaluated: an educational intervention regarding CBC-DIFF uses and a reprioritization of ED CBC-DIFF and CBC in the electronic medical record (EMR) orders. Pearson χ2 tests were used to assess for differences in the proportions.

Results

There was no difference in the proportion of CBC tests performed after the education intervention (175/6,192, 2.8% [95% CI, 2.39%-3.21%] vs 219/6,270, 3.5% [95% CI, 3.05%-3.95%]). There was a significant increase in CBC samples ordered following the EMR intervention (604/6,044, 9.1% [95% CI, 8.37%-9.83%]; P < .01).

Conclusions

Reprioritizing EMR laboratory orders can reduce overutilization of CBC-DIFF testing.

Preanalytic Factors Associated With Hemolysis in Emergency Department Blood Samples

Context.—

Hemolysis of emergency department blood samples is a common occurrence and has a negative impact on health care delivery.

Objectives.—

To determine the effect of preanalytic factors (straight stick, intravenous [IV] line, needle gauge, location of blood draw, syringe versus vacuum tube use, tourniquet time) on hemolysis in emergency department blood samples.

Design.—

A single 65 000-visit emergency department's electronic health record was queried for emergency department potassium results and blood draw technique for all samples obtained in calendar year 2014, resulting in 54 531 potassium results. Hemolyzed potassium was measured by hemolysis index. Comparisons of hemolysis by sampling technique were conducted by χ2 tests.

Results.—

Overall hemolysis was 10.0% (5439 of 54 531). Hemolysis among samples obtained from straight stick was significantly less than among those obtained with IV line (5.4% [33 of 615] versus 10.2% [4821 of 47 266], P &lt; .001). For IV-placed blood draws, antecubital location had a statistically significant lower overall hemolysis compared with other locations: 7.4% (2117 of 28 786) versus 14.6% (2622 of 17 960) (P &lt; .001). For blood drawn with a syringe compared with vacuum, hemolysis was 13.0% (92 of 705) and 11.0% (1820 of 16 590), respectively (P = .09, not significant). For large-gauge IV blood draws versus smaller-gauge IV lines, a lower hemolysis was also observed (9.3% [3882 of 41 571] versus 16.7% [939 of 5633]) (P &lt; .001). For IV-drawn blood with tourniquet time less than 60 seconds, hemolysis was 10.3% (1362 of 13 162) versus 13.9% for more than 60 seconds (532 of 3832), P &lt; .001.

Conclusions.—

This study confirmed previous findings that straight stick and antecubital location are significantly associated with reduced hemolysis and indicated that shorter tourniquet time and larger gauge for IV draws were significantly associated with lower hemolysis.

Impact of Use of Smaller Volume, Smaller Vacuum Blood Collection Tubes on Hemolysis in Emergency Department Blood Samples

OBJECTIVES

Hemolyzed blood samples commonly occur in hospital emergency departments (EDs). Our objective was to determine whether replacing standard large-volume/high-vacuum sample tubes with low-volume/low-vacuum tubes would significantly affect ED hemolysis.

METHODS

This was a prospective intervention of the use of small-volume/vacuum collection tubes. We evaluated all potassium samples in ED patients and associated hemolysis. We used χ2 tests to compare hemolysis incidence prior to and following utilization of small tubes for chemistry collection.

RESULTS

There were 35,481 blood samples collected during the study period. Following implementation of small-volume tubes, overall hemolysis decreased from a baseline of 11.8% to 2.9% (P < .001) with corresponding reductions in hemolysis with comment (8.95% vs 1.99%; P < .001) gross hemolysis (2.84% vs 0.90%; P < .007).

CONCLUSIONS

This work demonstrates that significant improvements in ED hemolysis can be achieved by utilization of small-volume/vacuum sample collection tubes.

Utility of Ecological Risk Factors for Evaluation of Transplant Center Performance

There is substantial evidence across different healthcare contexts that social determinants of health are strongly associated with morbidity and mortality in the United States. These factors, including socioeconomic status, behavior and environmental risks, education, social support, healthy food, and access to healthcare also vary widely by region and individual communities. One of the implications of heterogeneity in these risks is the potential impact on measured quality of healthcare providers. In particular, there is concern that providers treating disproportionally vulnerable communities may be disadvantaged by lack of risk adjustment for these factors that affect health but not indicators of quality of care. Recently, the National Quality Forum has endorsed risk adjustment for sociodemographic characteristics based on these concerns. These issues are salient to transplant programs since social determinants of health impact transplant patient outcomes and vary by region. In this viewpoint, we argue that integration of ecological (area-level) factors in risk adjustment models used to assess transplant center quality should be strongly considered. We believe this reform could be accomplished rapidly, would attenuate disparities in access to care by reducing disincentives to treat patients from vulnerable communities, and improve risk adjustment and calibration of models used for center evaluations.

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?

INTRODUCTION

Our goal was to determine if the hemolysis among blood samples obtained in an emergency department and then sent to the laboratory in a pneumatic tube system was different from those in samples that were hand-carried.

METHODS

The hemolysis index is measured on all samples submitted for potassium analysis. We queried our hospital laboratory database system (SunQuest(®)) for potassium results for specimens obtained between January 2014 and July 2014. From facility maintenance records, we identified periods of system downtime, during which specimens were hand-carried to the laboratory.

RESULTS

During the study period, 15,851 blood specimens were transported via our pneumatic tube system and 92 samples were hand delivered. The proportions of hemolyzed specimens in the two groups were not significantly different (13.6% vs. 13.1% [p=0.90]). Results were consistent when the criterion was limited to gross (3.3% vs 3.3% [p=0.99]) or mild (10.3% vs 9.8% [p=0.88]) hemolysis. The hemolysis rate showed minimal variation during the study period (12.6%-14.6%).

CONCLUSION

We found no statistical difference in the percentages of hemolyzed specimens transported by a pneumatic tube system or hand delivered to the laboratory. Certain features of pneumatic tube systems might contribute to hemolysis (e.g., speed, distance, packing material). Since each system is unique in design, we encourage medical facilities to consider whether their method of transport might contribute to hemolysis in samples obtained in the emergency department.

Impact of Frailty and Sociodemographic Factors on Hospital Admission From an Emergency Department Observation Unit

Understanding factors associated with an increased risk of hospital admission from emergency department (ED) observation units (OUs) could be valuable in disposition decisions. To evaluate the impact of frailty and sociodemographic factors (SDFs) on admission risk, patients in an ED OU were surveyed. Survey measures included SDFs, social habits, and frailty measured by the Katz Index of Independence in Activities of Daily Living. Of 306 surveyed, 18% were admitted and 82% were discharged. Demographics were similar between groups. More admitted patients responded positively to the Katz Index (28% vs 13%, P = .007; odds ratio = 2.73; 95% CI = 1.35-5.51). College graduation and current employment favored the discharge group, while admitted patients were more likely to receive Social Security disability insurance. Frailty remained associated with admission on multivariable analysis. Frailty, disability insurance, and lower education are predictors of admission from an OU and could serve as screening criteria in disposition decisions.

Emergency Department Visits after Kidney Transplantation

BACKGROUND AND OBJECTIVES

In 2011, there were approximately 131 million visits to an emergency department in the United States. Emergency department visits have increased over time, far outpacing growth of the general population. There is a paucity of data evaluating emergency department visits among kidney transplant recipients. We sought to evaluate the incidence and risk factors for emergency department visits after initial hospital discharge after transplantation in the United States.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We identified 10,533 kidney transplant recipients from California, New York, and Florida between 2009 and 2012 using the State Inpatient and Emergency Department Databases included in the Healthcare Cost and Utilization Project. We used multivariable Poisson and Cox proportional hazard models to evaluate adjusted incidence rates and time to emergency department visits after transplantation.

RESULTS

There were 17,575 emergency department visits over 13,845 follow-up years (overall rate =126.9/100 patient-years; 95% confidence interval, 125.1 to 128.8). The cumulative incidences of emergency department visits at 1, 12, and 24 months were 12%, 40%, and 57%, respectively, with median time =19 months; 48% of emergency department visits led to hospital admission. Risk factors for higher emergency department rates included younger age, women, black and Hispanic race/ethnicity, public insurance, depression, diabetes, peripheral vascular disease, and emergency department use before transplant. There was wide variation in emergency department visits by individual transplant center (10th percentile =70.0/100 patient-years; median =124.6/100 patient-years; and 90th percentile =187.4/100 patient-years).

CONCLUSIONS

The majority of kidney transplant recipients will visit an emergency department in the first 2 years post-transplantation, with significant variation by patient characteristics and individual centers. As such, coordination of care through the emergency department is a critical component of post-transplant management, and specific acumen of transplant-related care is needed among emergency department providers. Additional research assessing best processes of care for post-transplant management and health care expenditures and outcomes associated with emergency department visits for transplant recipients are warranted.

Chief complaint-based performance measures: a new focus for acute care quality measurement

Performance measures are increasingly important to guide meaningful quality improvement efforts and value-based reimbursement. Populations included in most current hospital performance measures are defined by recorded diagnoses using International Classification of Diseases, Ninth Revision codes in administrative claims data. Although the diagnosis-centric approach allows the assessment of disease-specific quality, it fails to measure one of the primary functions of emergency department (ED) care, which involves diagnosing, risk stratifying, and treating patients' potentially life-threatening conditions according to symptoms (ie, chief complaints). In this article, we propose chief complaint-based quality measures as a means to enhance the evaluation of quality and value in emergency care. We discuss the potential benefits of chief complaint-based measures, describe opportunities to mitigate challenges, propose an example measure set, and present several recommendations to advance this paradigm in ED-based performance measurement.

Abstract T P308: Re-assessment of Lipid Profiles in Stroke Patients Post-hospital Discharge - Room for Improvement

Introduction: According to guidelines patients receiving a lipid-lowering agent at discharge for stroke should receive follow-up lipid profile. Our measure takes the currently collected STK-6, one step further and tries to identify whether these patients receive follow-up lipid testing by comparing non-abstracted electronic health record data to abstracted data.

Methods: Data was extracted from the Cleveland Clinic EMR (Epic Systems, Inc.) utilized by the Cleveland Clinic Health System (10 hospitals and 16 family health centers). The cohort was based on patients with an admission for stroke from 2008 to 2012 utilizing STK-6 criteria. We examined this cohort for whether they received a lipid panel within the 12 months after the discharge date and limited patients to those that received follow up encounters at our healthcare system. Demographic factors including age, gender, race, ethnicity, distance to hospital, primary diagnosis for hospitalization and presence of comorbid conditions were also extracted. This data was compared to our abstracted publically reported STK-6 data which comes from claims data.

Results: Of the 508 patients included in results for STK-6 reporting, only 391 (77%) were also identified through the EMR. Of these, 274 patients had follow up at least one year within the healthcare system. Only 97(35%) patients had lipid panel lab results indicated in the EMR within one year of discharge. Testing was not statistically different based on patient characteristics: patients < 70 yrs vs 70+ (37% vs 30%, p=0.27), whites vs non-whites (35% vs. 36%, p=0.93), males vs. females (39% vs 30%, p=0.12). There was no significant difference in distance to the hospital from patients primary residence either between those without and with follow up lipid testing (mean distance=39 miles vs.17 miles, p=0.22).

Conclusions: Follow up lipid testing following stroke discharge is not consistently performed among patients treated at a large healthcare system. There are not any highly significant differences in testing based on patient demographic characteristics or distance to the hospital. Further understanding of the reasons for poor follow up testing is required as well as evaluating concordance of the data pulled from the EMR when compared to abstracted data.

Quality and safety implications of emergency department information systems

The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services "meaningful use" incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals' electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital's or physician group's approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order-wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system's ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or enterprise systems.

Methicillin-resistant Staphyloccocus aureus heel abscess: an uncommon emergency department diagnosis

Heel abscesses present as heel pain that progressively worsens, with associated tenderness and fullness at the heel pad. Radiological studies like computed tomography, magnetic resonance imaging, or ultrasound can help correctly diagnose a heel pad abscess. Generally, these patients require i.v. antibiotics and operative management to adequately drain the abscess. It is recommended to avoid incising the plantar aspect of the heel to minimize chronic post-drainage heel pain.

Defining and measuring successful emergency care networks: a research agenda

The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for "regionalized, coordinated, and accountable emergency care systems throughout the country." There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled "Beyond Regionalization: Integrated Networks of Emergency Care." This article is a product of the conference breakout session on "Defining and Measuring Successful Networks"; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non-time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM's vision of regionalized, coordinated, and accountable emergency care systems.

A pilot study to examine research subjects' perception of participating in research in the emergency department

STUDY OBJECTIVES

The emergency department (ED) provides an arena for patient enrollment into a variety of research studies even for non-critically ill patients. Given the types of illness, time constraints and sense of urgency that exists in the ED environment, concern exists about whether research subjects in the ED can provide full consent for participation. We sought to identify enrolled research subjects' perspectives on the informed consent process for research conducted in the ED.

METHODS

This was a prospective, observational study of ED subjects, 18&emsp14;years or older, who had been approached to participate in research in the ED and who were judged to have decision-making capacity. Exclusions were critical illness and refusal to participate. Subjective were followed up within 1&emsp14;week after enrolling using structured phone interviews by trained interviewers.

RESULTS

During the study period, 229 eligible patients were approached to participate in both a target study and this study. Of these, 66% (150/229) agreed to participate in this study, at least to the extent of allowing us access to their demographic data. The study participant group was similar in terms of gender to this particular ED's patient population but had significantly more African-Americans and persons older than 45.

CONCLUSION

Despite rigorous time constraints and rapid throughput times, the majority of subjects who consented to research participation in the ED felt that they were sufficiently informed and had adequate time to decide to participate.

Markedly elevated lipase as a clue to diagnosis of small bowel obstruction after gastric bypass

We describe an afferent loop obstruction in a patient who had a subtotal gastrectomy with Roux-en Y gastrojejunostomy for postvagotomy syndrome. The clinical presentation and initial studies suggested acute pancreatitis. A computed tomography scan showed a small bowel obstruction distal to the jejunojejunal anastomosis. The patient was taken to the operating room for an exploratory laparotomy, lysis of adhesions, and closure of her jejunostomy. Surgery was successful at resolving her obstruction. In any Roux-en-Y gastric reconstruction or gastric bypass patient presenting to the emergency department with abdominal pain and elevated transamines or pancreatic enzymes, a small bowel obstruction must be considered. Additional imaging with a computed tomography scan is advocated, as well as surgical consultation.

Improving handoffs in the emergency department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Radiographic detection of perflubron fluoromediastinum and fluororetroperitoneum 9 years after partial liquid ventilation

A 17-year-old patient presented, after a motor vehicle collision, with right hip pain and unusual radiographs of the chest and pelvis. Multiple radiopacities obscured detail. These partly obscured and distracted attention from a right acetabular fracture. The etiology was persistent perflubron 9 years after partial liquid ventilation for acute respiratory distress syndrome. Persistence of perflubron beyond 138 days has not been previously reported. We review the imaging appearance of perflubron and the mechanism likely related to its distribution and persistence in this case, and emphasize the importance of obtaining clinical history and avoiding distraction when faced with unusual radiographic findings.

Use of the endotracheal bougie introducer for difficult intubations

A difficult to intubate patient occurs infrequently in the emergency department. The endotracheal tube introducer or gum elastic bougie is a device used by British anesthesiologists in difficult airways. The device is inexpensive, has few complications and is easy to use. Similar to the Seldinger technique for gaining access to a large central vein, the endotracheal tube introducer is used to assist in cannulating the trachea and acts like the wire in central vein access.

A novel use of the endocavity (transvaginal) ultrasound probe: central venous access in the ED

Use of ultrasound (US) to obtain intravenous access is usually accomplished with a 7.5-MHz linear US probe. This paper describes the use of an endocavity US probe to obtain vascular access. Since both probes use US of the same megahertz values, the picture quality with the two is no different. Because the equipment used for each type of probe costs thousands of dollars, the economic value of having to purchase one less probe may be significant.

Paramedic use of the endotracheal tube introducer in a difficult airway model

OBJECTIVES

To determine whether advanced life support (ALS)-level prehospital providers can be taught to effectively use the Flex-Guide (FG) Endotracheal Tube (ETT) introducer in a difficult airway model by comparing success of styleted ETT intubation with Flex-Guide-assisted intubation.

METHODS

Intermediate and advanced providers, who brought patients to a Level 1 emergency department, were given a handout and viewed an instructional video describing the bougie and its use. A difficult airway was simulated using the CPR 5000 model mannequin from Medical Plastics Laboratory, Inc. The tongue was inflated to a pressure of 180 mm Hg to partially obscure the view of the airway and a cervical collar was placed to limit flexion and extension. Participants were then asked to intubate the mannequin using both the ETT with a stylet and the bougie-assisted method. Whether the providers used the FG or stylet method first was randomized. Success or failure was recorded and the McNemar test was used to evaluate the paired nonparametric data.

RESULTS

A total of 96 providers (66% advanced, 34% intermediate) were enrolled, 69 successfully intubated using the FG, while 64 successfully intubated with the stylet. Comparing successful bougie intubations with successful stylet intubations using the McNemar test, no significant difference was found between the groups (p = 0.486).

CONCLUSION

Prehospital care providers were as successful intubating a difficult airway model using the newly learned bougie technique as they were using the more familiar styleted ETT technique.