Whether patients present to the emergency department (ED) with physical ailments and comorbid psychiatric needs or primary psychiatric complaints, understanding differences in clinically relevant age ...and sex patterns over time is crucial to optimal psychiatric care in the ED setting. We used population-level surveillance data provided by the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) from January 1, 2008, through December 31, 2014. Mental health-related (MHR) ED visits were identified by International Classification of Diseases, Clinical Modification 9th revision (ICD-9-CM) codes analyzed in the Agency for Healthcare Research and Quality (AHRQ) clinical classification software groupings of related diagnostic categories. Trends were assessed based on total and average annual visit counts. We identified approximately 4 million MHR ED visits. The average number of visits per year was highest among 50-year-olds, while patients over the age of 90 had the highest proportion of their ED visits associated with an MHR code. Mood disorders were more prevalent among females, while substance use disorders were more prevalent among males. Within MHR categories, age-related peaks did not differ by sex except for suicide and self-inflicted injury. Whether it be a teenage boy presenting with suicidal ideation, a middle-aged man presenting with alcohol abuse, or an elderly female presenting with dementia, ED MHR visits’ needs vary across the lifespan. Understanding these trends is important to holistic patient care.
•Middle aged adults had the largest average annual number of mental health-related visits.•Geriatric adults were most likely to have a mental health comorbidity with their ED visit.•Visits associated with suicide/self-injury had the largest annual growth rates.•Mood disorders drove the presentation of female patients to the ED.•Substance use disorders were more common among male patients.
For many cancer patients, immune checkpoint inhibitors (ICIs) can be life-saving. However, the immune-related adverse events (irAEs) from ICIs can be debilitating and can quickly become severe or ...even be fatal. Often, irAEs will precipitate visits to the emergency department (ED). Therefore, early recognition and the decision to admit, observe, or discharge these patients from the ED can be key to a cancer patient's morbidity and mortality. ED clinicians typically make their decision for disposition (admit, observe, or discharge) within 2-6 h from their patient's ED presentation. However, irAEs are particularly challenging in the ED because of atypical presentations, the absence of classic symptoms, the delayed availability of diagnostic tests during the ED encounter, and the fast pace in the ED setting. At present, there is no single sufficiently large ED data source with clinical, biological, laboratory, and imaging data that will allow for the development of a tool that will guide early recognition and appropriate ED disposition of patients with potential irAEs. We describe an ongoing federally funded project that aims to develop an immune-related emergency disposition index (IrEDi). The project capitalizes on a multi-site collaboration among 4 members of the Comprehensive Oncologic Emergency Research Network (CONCERN): MD Anderson Cancer Center, Ohio State University, Northwestern University, and University of California San Diego. If the aims are achieved, the IrEDi will be the first risk stratification tool derived from a large racial/ethnically and geographically diverse population of cancer patients. The future goal is to validate irEDi in general EDs to improve emergency care of cancer patients on ICIs.
Abstract
Patients with cancer represent a growing population of patients seeking acute care in emergency departments (ED) nationwide. Emergency physicians are expected to provide excellent, ...consistent care to all ED patients; however, emergency medicine (EM) education and training of acute oncology is lacking.
To explore this topic, the Society for Academic Emergency Medicine Oncologic Emergencies Interest Group recruited experts in the field to provide a narrative description of the current state of EM education relating to acute oncology. This review of expert opinions explores the current state of acute oncology education in EM and identifies key content gaps that merit early investment.
Current emergency physician training and knowledge relating to acute oncology likely reflects the American Board of Emergency Medicine Model of Clinical Practice. Key topics such as immunotherapy are absent from the most recent revision of the Model of Clinical Practice and consequently represent a knowledge gap for large numbers of emergency physicians. Additionally, there is limited penetration of guideline-based care for symptom management in the ED setting. As such, additional attention should be provided to training programs and research efforts to address these knowledge gaps.
In conclusion, the current state of acute oncology education and training of emergency physicians is lacking and merits significant investment to assure the ability of emergency physicians to provide superior care for the growing population of patients with cancer.
Abstract
Background
Patients with cancer visit the emergency department often and have a high rate of admission compared to other patients. Admission rates by institution may vary widely, even after ...accounting for patient and hospital-specific characteristics.
Objectives
To review the variables that affect admission rates among patients with cancer in the emergency department.
Methods
We performed a secondary analysis of a prospective cohort study of patients with cancer at 18 emergency departments between March 1, 2016, and January 30, 2017, to examine differences in patient populations between hospitals with varying admission rates. We calculated the percentage admitted by hospital and used it to categorize hospitals into quartiles. We compared outcomes, patient demographics, and disease characteristics between the admission quartiles using linear or logistic regression.
Results
A total of 1075 patients were included. The median age of our sample was 64, and 51% of patients were female, 84% were white, and 13% were Black. Of the 1075 patients, 615 (57.2%) were admitted as inpatients with a range from 21.2 to 81.7% by hospital. Differences between admission quartiles were found for education, mode of arrival, and recent chemotherapy (
p
< 0.05). There were no significant differences among quartiles in age, gender, race, or ECOG score. We found significant difference between admission quartiles in 30-day emergency department revisits. Differences in readmission rates and mortality did not appear to be significant between the various quartiles.
Conclusions
In our study, we observed several differences among patients with cancer receiving care at hospitals with different admission rates. These included patients’ education level, mode of arrival, and whether they had received recent chemotherapy. Emergency Severity Index (ESI) score may have also contributed to admission rate variability. Further study into unmeasured factors influencing hospital admissions, such as local culture, resources, and pathways, could identify generalizable findings to reduce avoidable admissions and reduce variation among similar patients in different hospitals.
Emergency department observation units (EDOUs) are effective and increasingly utilized in the delivery of short-term care. These units decrease length of stay and cost while increasing patient ...satisfaction and safety. Currently, EDOUs are underutilized for patients with cancer. We aimed to characterize the care of patients with cancer in an academic type 1 EDOU.
Retrospective review of EDOU quality data at an academic medical center with a Comprehensive Cancer Center (CCC). Eligible encounters included patients ≥ 18 cared for in the EDOU between July 1, 2019, and December 31, 2022. Patients with cancer were identified using an oncology triage screen during ED intake defined as a self-report of an active cancer or receiving care at the associated CCC. Descriptive statistics were employed to describe demographics, chief complaint, and assigned EDOU protocol. Pearson's chi-squared test was performed to determine statistically significant differences among patients with and without cancer. Due to dataset limitations, it was impossible to remove EDOU subjects with cancer treated for noncancer-related reasons.
From 15,089 eligible EDOU encounters, 1,711 (11.3%) involved patients with cancer – 348, 548, 444, and 371 visits in 2019, 2020, 2021, and 2022 respectively. In the cohort with cancer, most patients were White (1,353, 79.1%) with a slight female predominance (905, 52.9%) noted. Furthermore, unspecified (148, 8.6%), chest pain (127, 7.4%), and abdominal pain (93, 5.4%) were the top chief complaints. In patients with cancer, 1,234 (72.1%) encounters resulted in discharge, significantly lower than that observed in patients without cancer (10,408, 77.8%; p<0.001). In both groups, the general observation protocol was the most utilized order set. However, further analysis revealed a significantly increased use of the general observation protocol in patients with cancer compared to noncancer patients (25.4% and 14.0%, respectively; p<0.001).
Compared to patients without cancer, patients with cancer experience a significantly higher use of the general observation protocol suggesting that further optimization and development of novel cancer-specific EDOU protocols is warranted.
More than 80% of patients who present to the emergency department (ED) with acute heart failure (AHF) are hospitalized. With more than 1 million annual hospitalizations for AHF in the US, safe and ...effective alternatives are needed. Care for AHF in short-stay units (SSUs) may be safe and more efficient than hospitalization, especially for lower-risk patients, but randomized clinical trial data are lacking.
To compare the effectiveness of SSU care vs hospitalization in lower-risk patients with AHF.
This multicenter randomized clinical trial randomly assigned low-risk patients with AHF 1:1 to SSU or hospital admission from the ED. Patients received follow-up at 30 and 90 days post discharge. The study began December 6, 2017, and was completed on July 22, 2021. The data were analyzed between March 27, 2020, and November 11, 2023.
Randomized post-ED disposition to less than 24 hours of SSU care vs hospitalization.
The study was designed to detect at least 1-day superiority for a primary outcome of days alive and out of hospital (DAOOH) at 30-day follow-up for 534 participants, with an allowance of 10% participant attrition. Due to the COVID-19 pandemic, enrollment was truncated at 194 participants. Before unmasking, the primary outcome was changed from DAOOH to an outcome with adequate statistical power: quality of life as measured by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). The KCCQ-12 scores range from 0 to 100, with higher scores indicating better quality of life.
Of the 193 patients enrolled (1 was found ineligible after randomization), the mean (SD) age was 64.8 (14.8) years, 79 (40.9%) were women, and 114 (59.1%) were men. Baseline characteristics were balanced between arms. The mean (SD) KCCQ-12 summary score between the SSU and hospitalization arms at 30 days was 51.3 (25.7) vs 45.8 (23.8) points, respectively (P = .19). Participants in the SSU arm had 1.6 more DAOOH at 30-day follow-up than those in the hospitalization arm (median IQR, 26.9 24.4-28.8 vs 25.4 22.0-27.7 days; P = .02). Adverse events were uncommon and similar in both arms.
The findings show that the SSU strategy was no different than hospitalization with regard to KCCQ-12 score, superior for more DAOOH, and safe for lower-risk patients with AHF. These findings of lower health care utilization with the SSU strategy need to be definitively tested in an adequately powered study.
ClinicalTrials.gov Identifier: NCT03302910.
Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED ...with active cancer.
Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017.
Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics.
We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.
Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer ...position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees' performance on ETI delivered from both the seated and standing positions.
EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests.
Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training.
The position of the in-hospital provider, whether seated or standing, had no effect on the provider's ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.
Objective
The American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (ABEM Model) serves as a guide for resident education and the basis for the resident ...In‐training Examination (ITE) and the Emergency Medicine Board Qualification Examinations. The purpose of this study was to determine how closely resident–patient encounters in our emergency departments (EDs) matched the ABEM Model as presented in the specifications of the content outline for the ITE.
Methods
This single‐site study of an academic residency program analyzed all documented resident–patient encounters in the ED during a 2.5‐year period recorded in the electronic medical record. The chief complaints from these encounters were matched to the 20 categories of the ABEM Model. Chi‐square goodness‐of‐fit tests were performed to compare the proportions of categorized encounters and proportions of patient acuity levels to the proportions of categories as outlined in the content blueprint of the ITE.
Results
After the exclusion of encounters with missing data and those not involving EM residents, 125,405 encounters were analyzed. We found a significant difference between the clinical experience of EM residents and the ABEM Model as reflected in the ITE for both case categories (p < 0.01) and patient acuity (p < 0.01). The following categories were the most overrepresented in clinical care: signs, symptoms, and presentations; psychobehavioral disorders; and abdominal and gastrointestinal disorders. The most underrepresented were procedures and skills, systemic infectious disorders, and thoracic–respiratory disorders.
Conclusion
The clinical experience of EM residents differs significantly from the ITE Content Blueprint, which reflects the ABEM Model. This type of inquiry may help to provide custom education reports to residents about their clinical encounters to help identify clinical knowledge gaps that may require supplemental nonclinical training.
BackgroundThe COVID-19 pandemic has provided an opportunity for significant reflection on our public health response as providers. Throughout the past two years, we learned that administration of ...COVID-19 vaccines, rapidly and widely across all communities, has been key to halting the spread of the virus. One significant challenge in promoting a large-scale immunization program is the threat of vaccine hesitancy. A general mistrust in healthcare providers exists across the country, especially in underrepresented minority (URM) communities.ObjectiveThis study aims to determine reasons for vaccine hesitancy in an urban emergency department and to provide targeted education on the safety and efficacy of the COVID-19 vaccines to patients.MethodsAn interprofessional quality improvement team was assembled to develop an educational intervention addressing COVID-19 vaccine safety for vaccine-eligible patients receiving treatment in the emergency department at an urban community hospital where over 70% of patients identify as URM. A survey was conducted to elucidate patients’ concerns surrounding the COVID-19 vaccine. Upon completion of the survey, up-to-date safety information and education targeting their surveyed concerns were provided by trained medical students. A follow-up survey was conducted to assess the impact of education on patients’ attitudes toward the vaccine. Surveys were developed using standardized scoring systems from the Oxford coronavirus explanations, attitudes, and narratives survey (OCEANS) II study and the Kaiser Foundation. Hesitancy scores before and after education were tabulated to assess the effectiveness of targeted education in improving vaccine hesitancy.ResultsPatients cited a variety of concerns surrounding the COVID-19 vaccine. The three most common reasons for declining vaccines were potential side effects (67.3% were concerned or extremely concerned), the belief that COVID-19 vaccines are neither effective nor safe (64.5% were concerned to extremely concerned), and the risk of developing COVID-19 infection from the vaccine itself (38.8% were concerned to extremely concerned). This information was used to address these concerns directly with patients, answer questions, clarify information, and encourage patients to get vaccinated. Through this education program, vaccine hesitancy scores improved by an average of 29% indicating an increased likelihood of patients who would get vaccinated in the future. Of patients receiving education, 38% agreed to sign up for a vaccine appointment during the intervention.ConclusionThe emergency department often serves vulnerable patient populations. As such, its role in public health in these communities cannot be underestimated. This quality improvement project is a novel method that can be used to develop and implement public health education programs to address specific community needs in the emergency department. These results show that a multidisciplinary healthcare team can provide a measurable change in attitudes about vaccine safety with directed education in the emergency department that can help address vaccine hesitancy in the future.
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