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All EDs used the same electronic medical record (EMR) (EPIC Systems, Verona WI) allowing for data acquisition. Strategies are needed to proactively manage risk in vulnerable populations and assure adequate access.Grants/financial support No outside funding provided support for this project. Category EMSa ED Encounters 2019 2020 % Change Overall EMS 10,958 7889 −28.01% Not EMS 45,495 23,498 −48.35% Overall Total 56,453 31,387 −44.40% Comprehensive BH EMS 1781 1438 −19.26% Not EMS 1657 1039 −37.30% Comprehensive BH Total 3438 2477 −27.95% Suicidal Chief Complaints and Orders EMS 567 245 −56.79% Not EMS 577 206 −64.30% Suicidal Total 1144 451 −60.58% Alcohol Chief Complaints and Dx EMS 599 512 −14.52% Not EMS 372 317 −14.78% Alcohol Total 971 829 −14.62% Table 1 Overall ED encounters, behavioral health complaints, suicide, and alcohol chief complaints in the healthcare system.

Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system. This retrospective, multicenter study examined all encounters from January 1-December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system. In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.

Introduction: Two protocols were developed to guide the use of subdissociative dose ketamine (SDDK) for analgesia and dissociative sedation ketamine for severe agitation/excited delirium in the emergency department (ED). We sought to evaluate the safety of these protocols implemented in 18 EDs within a large health system. Methods: We conducted a retrospective chart review to evaluate all adult patients who received intravenous (IV) SDDK for analgesia and intramuscular (IM) dissociative sedation ketamine for severe agitation/excited delirium in 12 hospital-based and six freestanding EDs over a one-year period from the protocol implementation. We developed a standardized data collection form and used it to record patient information regarding ketamine use, concomitant medication use, and any comorbidities that could have impacted the incidence of adverse events. Results: Approximately 570,000 ED visits occurred during the study period. SDDK was used in 210 ED encounters, while dissociative sedation ketamine for severe agitation/excited delirium was used in 37 ED encounters. SDDK was used in 83% (15/18) of sites while dissociative sedation ketamine was used in 50% (9/18) of sites. Endotracheal intubation, non-rebreather mask, and nasal cannula ≥ four liters per minute were identified in one, five, and three patients, respectively. Neuropsychiatric adverse events were identified in 4% (9/210) of patients who received SDDK. Conclusion: Patients experienced limited neuropsychiatric adverse events from SDDK. Additionally, dissociative sedation ketamine for severe agitation/excited delirium led to less endotracheal intubation than reported in the prehospital literature. The favorable safety profile of ketamine use in the ED may prompt further increases in usage.

There has only been one report thus far adding eye protection to universal masking, with no transmission to HCWs who added face shields in India during home visits [4]. The goal of our study was to determine if frontline emergency clinicians contracted COVID-19 at a rate different from that predicted by community spread when implementing mandatory eye protection (in addition to masks). COVID-19 infection occurred among our frontline ED clinicians at a rate more comparable to community spread than to the prevalence in our ED patient population.

Overdose from opioids has reached epidemic proportions. Large healthcare systems can utilize existing technology to encourage responsible opioid prescribing practices. Our study measured the effects of using the electronic medical record (EMR) with direct clinician feedback to standardize opioid prescribing practices within a large healthcare system. This retrospective multicenter study compared a 12 month pre- and post-intervention in 14 emergency departments after four interventions utilizing the EMR were implemented: (1) deleting clinician preference lists, (2) defaulting dose, frequency, and quantity, (3) standardizing formulary to encourage best practices, and (4) creating dashboards for clinician review with current opioid prescribing practices. Outlying clinicians received feedback through email and direct counseling. Total number of opioid prescriptions per 100 discharges pre- and post-intervention were recorded as primary outcome. Secondary outcomes included number of prescriptions per 100 discharges/clinician exceeding 3-day supply (defined as 12 tablets), number exceeding 30 morphine equivalent daily dose (MEDD)/day, and number of non-formulary prescriptions. There were >700,000 discharges during pre- and post-intervention periods. Percentage of total number opioid prescriptions per 100 discharges decreased from 14.4% to 7.4%, a 7.0% absolute reduction, (95% CI,6.9%–7.2%). There was a 5.9% to 0.7% reduction in prescriptions exceeding 3-days, (95% CI, 5.1%–5.3%), a 4.3% to 0.3% reduction in prescriptions exceeding 30 MEDD, (95% CI, 3.9%–4.0%), and a 0.3% to 0.1% reduction in non-formulary prescriptions, (95% CI, 0.2%–0.3%). A multi modal approach using EMR interventions which provide real time data and direct feedback to clinicians can facilitate appropriate opioid prescribing.

Aims To determine whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol is associated with reduced sex disparities over 5 years. Methods and results This was an observational cohort study of 1833 consecutive STEMI patients treated with percutaneous coronary intervention (PCI) before (1 January 2011–14 July 2014, control group) and after (15 July 2014–15 July 2019, protocol group) implementation of a protocol for early guideline-directed medical therapy (GDMT), rapid door to balloon time (D2BT), and use of trans-radial PCI. In the control group, females had less GDMT (77.1% vs. 68.1%, P = 0.03), similarly low trans-radial PCI (19.0% vs. 17.6%, P = 0.73), and longer D2BT [104 min (79, 133) vs. 112 min (85, 147), P = 0.02] corresponding to higher in-hospital mortality [4.5% vs. 10.3%, odds ratio (OR) 2.44 (1.34–4.46), P = 0.004], major adverse cardiac and cerebrovascular events [MACCE, 9.8% vs. 16.3%, OR 1.79 (1.14–2.84), P = 0.01], and net adverse clinical events [NACE, 16.1% vs. 28.3%, OR 2.06 (1.42–2.99), P < 0.001]. In the protocol group, no significant sex differences were observed in GDMT (87.2% vs. 86.4%, P = 0.81) or D2BT [85 min (64–106) vs. 89 min (65–111), P = 0.06], but trans-radial PCI was used less in females (77.6% vs. 71.2%, P = 0.03). In-hospital mortality [2.5% vs. 4.4%, OR 1.78 (0.91–3.51), P = 0.09] and MACCE [9.0% vs. 11.1%, OR 1.27 (0.83–1.92), P = 0.26] were similar between sexes, but higher NACE in females approached significance [14.8% vs. 19.4%, OR 1.38 (0.99–1.92), P = 0.05] due to higher bleeding risk [7.2% vs. 11.1%, OR 1.60 (1.04–2.46), P = 0.03]. Conclusions A comprehensive STEMI protocol was associated with sustained reductions for in-hospital ischaemic outcomes over 5 years, but higher bleeding rates in females persisted. Graphical Abstract Graphical Abstract A comprehensive STEMI protocol was associated with reduced STEMI sex disparities in care and outcomes for 5 years after protocol implementation. Key aspects of the protocol and in-hospital outcomes are summarized. MACCE, major adverse cardiovascular and cerebrovascular events; NACE, net adverse clinical events.

The objectives of this study were to determine the prevalence of use of abdominal computed tomography (CT) in older ED patients with acute nontraumatic abdominal pain, describe the most common diagnostic CT findings, and determine the proportion of diagnostic CT results. This was a prospective, observational, multicenter study of 337 patients 60 years or older. History was obtained prospectively; charts were reviewed for radiographic findings, dispositions, diagnoses, and clinical course, and patients were followed up at 2 weeks for additional information. The prevalence of use of abdominal CT was 37%. The most common diagnostic findings were diverticulitis (18%), bowel obstruction (18%), nephrolithiasis (10%), and gallbladder disease (10%). Eight percent of patients had findings suggestive of neoplasm. Overall, 57% of CT results were diagnostic (95% confidence interval [CI], 49%-66%), 75% (95% CI, 63%-84%) for patients requiring acute medical or surgical intervention, and 85% (95% CI, 62%-97%) for patients requiring acute surgical intervention. CT use is highly prevalent in older ED patients with acute abdominal pain. CT results are often diagnostic, especially for patients with emergent conditions.

Troponin T (TnT) elevations (≥0.1 ng/mL) indicate an increased risk of adverse outcomes in patients with acute coronary syndromes (ACS). There is little data on the prognostic significance of TnT in elders with ACS. We sought to define the ability of TnT to predict adverse outcomes in elders with suspected ACS compared with the younger cohort. This is a nested cohort study of patients aged <65 and ≥65 years with suspected ACS. Serial ECGs, CKMB and TnT assays were obtained at presentation and 4, 8, and 16 hours later. Adverse outcomes at hospital discharge included death, nonfatal myocardial infarction, coronary artery bypass grafting, and positive cardiac catheterization. A total of 695 patients were enrolled. A total of 301 (48%) were aged 65 or older. Although there was no difference in TnT sensitivity between the younger and older cohorts, there was a difference in specificity, 94% versus 83% ( P < .01), respectively. In both cohorts, renal insufficiency was associated with a significantly lower TnT specificity. In both elders and younger patients with abnormal renal function, low TnT specificity warrants careful consideration of this marker as the sole criterion for aggressive medical management.

Troponin T (TnT) elevations (≥0.1 ng/mL) indicate an increased risk of adverse outcomes in patients with acute coronary syndromes (ACS). There is little data on the prognostic significance of TnT in elders with ACS. We sought to define the ability of TnT to predict adverse outcomes in elders with suspected ACS compared with the younger cohort. This is a nested cohort study of patients aged <65 and ≥65 years with suspected ACS. Serial ECGs, CKMB and TnT assays were obtained at presentation and 4, 8, and 16 hours later. Adverse outcomes at hospital discharge included death, nonfatal myocardial infarction, coronary artery bypass grafting, and positive cardiac catheterization. A total of 695 patients were enrolled. A total of 301 (48%) were aged 65 or older. Although there was no difference in TnT sensitivity between the younger and older cohorts, there was a difference in specificity, 94% versus 83% (P < .01), respectively. In both cohorts, renal insufficiency was associated with a significantly lower TnT specificity. In both elders and younger patients with abnormal renal function, low TnT specificity warrants careful consideration of this marker as the sole criterion for aggressive medical management.

Background Emergency medicine (EM) pharmacists may be uniquely positioned to optimize discharge prescriptions for emergency department (ED) patients but the clinical significance of interventions and association with patient outcomes are not well-described. Objective To evaluate the clinical significance of EM pharmacist interventions completed during review of ED discharge prescriptions. Setting This study was conducted in an academic medical center ED. Methods: This was a retrospective observational study of patients discharged with prescriptions from the ED over two months. EM pharmacists reviewed discharge prescriptions and provided drug therapy recommendations. Two independent reviewers rated the clinical significance of interventions. High risk criteria were proposed a priori and included in a multivariable logistic regression analysis to identify variables independently associated with pharmacist intervention. Main Outcome Measure The primary outcome measure was the rate, type, and clinical significance of interventions associated with EM pharmacist review of discharge prescriptions. Results A total of 3107 prescriptions for 1648 patients were reviewed. Interventions occurred for 7.3% of patients with 29% of interventions rated as significant. The intervention rate was higher in patients with at least 1 high risk criteria versus those without (9.6% vs. 3.7%, p < 0.0001). An incremental increase in the number of discharge prescriptions was independently associated with pharmacist intervention. The 30 day readmission rates did not differ between patients with and without pharmacist review (27.4% vs. 26.2%, p = 0.38). Conclusion: Pharmacist review of discharge prescriptions resulted in clinically significant interventions but did not impact readmission rates. An incremental increase in the number of discharge prescriptions was associated with pharmacist intervention.