Increased Length of Emergency Department Boarding Is Not Associated with Increased Mortality

Objectives: Prior studies have shown an association between longer ED boarding time and higher inpatient mortality. Questioning the external validity of these findings, we hypothesized that length of ED boarding is not associated with increased mortality. Methods: This was a retrospective cohort study. The setting was an urban, academic ED with \u3e 100,000 annual patient volume. We included consecutive adult hospital admissions over a 5-month period (September 2016 to January 2017). Patients were excluded that were admitted to labor and delivery or hospice care. We defined boarding time as the time between when an admitting order was placed and when the clerk on the admitting floor documented the patient\u27s arrival. The primary outcome was inpatient mortality. Analysis consisted of multivariable logistic regression that tested the association between boarding time and a poor outcome. Boarding time of 0 - 2 hours was used as the reference. Covariates in the model included age, sex, the Charlson comorbidity index, shock index, ventilator requirement, and abnormal routine labs. Results: There were 9,666 admissions from the ED. The mean age was 58 years, 52% were female, and 68% African American. The median ED LOS was 470 (IQR 360 - 612] minutes and the median boarding time was 180 [IQR 126 - 262] minutes. Boarding was more than 6 hours in 12.8% of admissions and more than 12 hours in 1.6% of admissions. Inpatient mortality was 2.4%, and 30-day mortality was 3.9%. Inpatient mortality based on boarding time was 2.9% (0-2 hours), 2.4% (2-4 hours), 2.4% (4-6 hours), and 1.2% (\u3e6 hours). When adjusting for age, sex, comorbidities and physiological abnormalities, there was no signal of higher inpatient or 30-day mortality with prolonged boarding. The odd ratios for inpatient mortality for boarding times of 2-4 and 4-6 hours compared to 0-2 hours were 0.76 (95% CI 0.54-1.06) and 0.80 (95% CI 0.52-1.22). The OR for inpatient mortality for patients with boarding time \u3e 6 hours was 0.39 (95% CI 0.21-0.73). Conclusion: While boarding time is a driver of poor patient satisfaction, these results question the existing literature their association with poor outcomes. Furthermore, the reduced odds of death with prolonged boarding (\u3e 6 hours) suggests that unaccounted for admitting processes, which preferentially keep patients with lesser morbidity in the ED, may be present

Cerebrovascular risks with rapid blood pressure lowering in the absence of hypertensive emergency.

STUDY OBJECTIVE: In the Emergency Department (ED) setting, clinicians commonly treat severely elevated blood pressure (BP) despite the absence of evidence supporting this practice. We sought to determine if this rapid reduction of severely elevated BP in the ED has negative cerebrovascular effects. METHODS: This was a prospective quasi-experimental study occurring in an academic emergency department. The study was inclusive of patients with a systolic BP (SBP) \u3e 180 mm Hg for whom the treating clinicians ordered intensive BP lowering with intravenous or short-acting oral agents. We excluded patients with clinical evidence of hypertensive emergency. We assessed cerebrovascular effects with measurements of middle cerebral artery flow velocities and any clinical neurological deterioration. RESULTS: There were 39 patients, predominantly African American (90%) and male (67%) and with a mean age of 50 years. The mean pre-treatment SBP was 210 ± 26 mm Hg. The mean change in SBP was -38 mm Hg (95% CI -49 to -27) mm Hg. The average change in cerebral mean flow velocity was -5 (95% CI -7 to -2) cm/s, representing a -9% (95% CI -14% to -4%) change. Two patients (5.1%, 95% CI 0.52-16.9%) had an adverse neurological event. CONCLUSION: While this small cohort did not find an overall substantial change in cerebral blood flow, it demonstrated adverse cerebrovascular effects from rapid BP reduction in the emergency setting

Thiamine Deficiency Is Common Among Emergency Department Oncology Patients

Background: Thiamine deficiency is associated with significant morbidity that may be precipitated by acute illness. Due to metabolic demands of cancer and difficulty maintaining adequate nutrition, oncology patients may be at higher risk of thiamine deficiency when acutely ill. Our primary objective was to quantify the prevalence of thiamine deficiency among ED oncology patients. Methods: This was a prospective, single center observational study. Inclusion criteria were adult patients with active malignancy presenting to the ED. We excluded patients with known cirrhosis or liver cancer due to known alterations in thiamine metabolism. Data collection included demographic and clinical information, including cancer type and albumin as a marker of nutritional status. We sent whole blood for thiamine levels (Warde Laboratories, Ann Arbor, MI). Analysis was descriptive but also included univariate analysis to test risk factors for thiamine deficiency. Results: There were 55 patients. The mean age was 63 ± 14 years, 53% were female, and 64% African American. The most common malignancies were lung (26%), colon (11%) and breast (11%) cancer. Metastatic disease was present in 43% of patients, and 52% of patients were undergoing current chemotherapy. Mean body mass index (BMI) and albumin were 26.7 ± 6.1 kg/m2 and 3.4 ± 0.8 g/dL, respectively. The rate of thiamine deficiency was 31% (95% CI 19 - 45%). There was no statistical difference in age (p=0.99), BMI (p=0.17), albumin (p=0.91), or gender (p=0.36) between patients with or without thiamine deficiency. 39% of patients with metastatic disease had thiamine deficiency compared to 23% without metastatic disease but the difference did not reach statistical significance (p=0.19). Conclusion: In this cohort of ED oncology patients, there was a surprisingly high rate of thiamine deficiency. Further work is indicated to delineate risk factors and attributable morbidity

Unique Risk Factors for Thiamine Deficiency in ED Patients without Alcohol Dependence

Background: Thiamine (vitamin B1) is a crucial component in multiple essential biochemical pathways, andB1deficiency is increasingly recognized as a treatment target in sepsis and other critical illnesses. Our objective was to determine risk factors for B1 deficiency in severely ill ED patients without a history of alcohol dependence. Methods: This was a multi-pronged, prospective observational study that assessed B1 levels in ED patients with diabetic ketoacidosis, severe sepsis, and oncological emergencies. We excluded patients that had known alcohol dependence or for whom the ED clinicians planned B1 treatment. Investigators collected whole blood levels on all patients in ED, which measure thiamine-diphosphate,the active form of B1. We collected demographic and clinical characteristics that could contribute to nutritional deficiencies. We collected data specific to metformin use as pre-clinical data suggests that metformin may interfere with intestinal B1 transporters. Analysis consisted of univariate comparisons and multivariable logistic regression to assess significant risk factors for the primary outcome of B1 deficiency, defined as a whole blood level below the normal reference range. Results: The study enrolled 342 patients, of whom the average age was 57 (SD 17) years, 47% were female, and 80% African American. In univariate analysis, patients with B1 deficiency had greater mean age (62 vs. 56 years, p = 0.007), lower mean albumin (2.9 vs. 3.5 g/dL, p \u3c 0.001), and similar body mass index (28 vs. 28, p = 0.81). Patients with B1 deficiency were more often female (24% vs. 14%, p = 0.023). Thiamine deficiency occurred most frequently in patients with severe sepsis (27%) and oncological emergencies (28%) compared to all other diagnoses (10%, p=0.002). Diabetics on metformin had significantly higher rates of B1 deficiency compared to those not on metformin (22% vs. 10%, p = 0.03). In multivariate analysis, the following clinical characteristics (OR, 95% CI) were associated with B1 deficiency: female gender 2.0 (1.1 - 3.7), history of cancer 2.2 (1.2 - 4.0), metformin use 2.6 (1.0 - 6.5), and low albumin 2.6 (1.2 - 5.3). Conclusions: In this study,independent risk factors for B1 deficiency were female gender, cancer, and low albumin. Furthermore, this is the first clinical data to indicate a significant association between metformin use and B1 deficiency.https://scholarlycommons.henryford.com/merf2019clinres/1016/thumbnail.jp

Unique risk factors for thiamine deficiency in patients without alcohol dependence

Background: Thiamine (vitamin B1) is a crucial component in multiple essential biochemical pathways, and B1 deficiency is increasingly recognized as a treatment target in sepsis and other critical illnesses. Our objective was to determine risk factors for B1 deficiency in severely ill ED patients without a history of alcohol dependence. Methods: This was a multi-pronged, prospective observational study that assessed B1 levels in ED patients with diabetic ketoacidosis, severe sepsis, and oncological emergencies. We excluded patients that had known alcohol dependence or for whom the ED clinicians planned B1 treatment. Investigators collected whole blood levels on all patients in ED, which measure thiamine-diphosphate, the active form of B1. We collected demographic and clinical characteristics that could contribute to nutritional deficiencies. We collected data specific to metformin use as pre-clinical data suggests that metformin may interfere with intestinal B1 transporters. Analysis consisted of univariate comparisons and multivariable logistic regression to assess significant risk factors for the primary outcome of B1 deficiency, defined as a whole blood level below the normal reference range. Results: The study enrolled 342 patients, of whom the average age was 57 (SD 17) years, 47% were female, and 80% African American. In univariate analysis, patients with B1 deficiency had greater mean age (62 vs. 56 years, p = 0.007), lower mean albumin (2.9 vs. 3.5 g/dL, p \u3c 0.001), and similar body mass index (28 vs. 28, p = 0.81). Patients with B1 deficiency were more often female (24% vs. 14%, p = 0.023). Thiamine deficiency occurred most frequently in patients with severe sepsis (27%) and oncological emergencies (28%) compared to all other diagnoses (10%, p=0.002). Diabetics on metformin had significantly higher rates of B1 deficiency compared to those not on metformin (22% vs. 10%, p = 0.03). In multivariate analysis, the following clinical characteristics (OR, 95% CI) were associated with B1 deficiency: female gender 2.0 (1.1-3.7), history of cancer 2.2 (1.2-4.0), metformin use 2.6 (1.0-6.5), and low albumin 2.6 (1.2-5.3). Conclusion: In this study, independent risk factors for B1 deficiency were female gender, cancer, and low albumin. Furthermore, this is the first clinical data to indicate a significant association between metformin use and B1 deficiency

Potential of Mobile Health Technology to Reduce Health Disparities in Underserved Communities.

INTRODUCTION: Mobile health (mHealth) has the potential to change how patients make healthcare decisions. We sought to determine the readiness to use mHealth technology in underserved communities. METHODS: We conducted a cross-sectional survey of patients presenting with low-acuity complaints to an urban emergency department (ED) with an underserved population. Patients over the age of two who presented with low-acuity complaints were included. We conducted structured interview with each patient or parent (for minors) about willingness to use mHealth tools for guidance. Analysis included descriptive statistics and univariate analysis based on age and gender. RESULTS: Of 560 patients included in the survey, 80% were adults, 64% female, and 90% Black. The mean age was 28 ± 9 years for adults and 9 ± 5 years for children. One-third of patients reported no primary care physician, and 55% reported no access to a nurse or clinician for medical advice. Adults were less likely to have access to phone consultation than parents of children (odds ratio [OR] 0.49, 95% confidence interval [CI], 0.32 - 0.74), as were males compared to females (OR 0.52, 95% CI, 0.37-0.74). Most patients (96%) reported cellular internet access. Two-thirds of patients reported using online references. When asked how they would behave if an mHealth tool advised them that their current health problem was low risk, 69% of patients responded that they would seek care in an outpatient clinic instead of the ED (30%), stay home and not seek urgent medical care (28%), or use telehealth (11%). CONCLUSION: In this urban community we found a large capacity and willingness to use mHealth technology in medical triage

Potential of Mobile Health Technology to Reduce Health Disparities in Underserved Communities

Introduction: Mobile health (mHealth) has the potential to change how patients make healthcare decisions. We sought to determine the readiness to use mHealth technology in underserved communities.Methods: We conducted a cross-sectional survey of patients presenting with low-acuity complaints to an urban emergency department (ED) with an underserved population. Patients over the age of two who presented with low-acuity complaints were included. We conducted  structured interview with each patient or parent (for minors) about willingness to use mHealth tools for guidance. Analysis included descriptive statistics and univariate analysis based on age and gender.Results: Of 560 patients included in the survey, 80% were adults, 64% female, and 90% Black. The mean age was 28 ± 9 years for adults and 9 ± 5 years for children. One-third of patients reported no primary care physician, and 55% reported no access to a nurse or clinician for medical advice. Adults were less likely to have access to phone consultation than parents of children (odds ratio [OR] 0.49, 95% confidence interval [CI], 0.32 – 0.74), as were males compared to females (OR 0.52, 95% CI, 0.37– 0.74). Most patients (96%) reported cellular internet access. Two-thirds of patients reported using online references. When asked how they would behave if an mHealth tool advised them that their current health problem was low risk, 69% of patients responded that they would seek care in an outpatient clinic instead of the ED (30%), stay home and not seek urgent medical care (28%), or use telehealth (11%).Conclusion: In this urban community we found a large capacity and willingness to use mHealth technology in medical triage

Potential of Mobile Health Technology to Reduce Health Disparities in Underserved Communities

INTRODUCTION: Mobile health (mHealth) has the potential to change how patients make healthcare decisions. We sought to determine the readiness to use mHealth technology in underserved communities. METHODS: We conducted a cross-sectional survey of patients presenting with low-acuity complaints to an urban emergency department (ED) with an underserved population. Patients over the age of two who presented with low-acuity complaints were included. We conducted structured interview with each patient or parent (for minors) about willingness to use mHealth tools for guidance. Analysis included descriptive statistics and univariate analysis based on age and gender. RESULTS: Of 560 patients included in the survey, 80% were adults, 64% female, and 90% Black. The mean age was 28 ± 9 years for adults and 9 ± 5 years for children. One-third of patients reported no primary care physician, and 55% reported no access to a nurse or clinician for medical advice. Adults were less likely to have access to phone consultation than parents of children (odds ratio [OR] 0.49, 95% confidence interval [CI], 0.32 - 0.74), as were males compared to females (OR 0.52, 95% CI, 0.37-0.74). Most patients (96%) reported cellular internet access. Two-thirds of patients reported using online references. When asked how they would behave if an mHealth tool advised them that their current health problem was low risk, 69% of patients responded that they would seek care in an outpatient clinic instead of the ED (30%), stay home and not seek urgent medical care (28%), or use telehealth (11%). CONCLUSION: In this urban community we found a large capacity and willingness to use mHealth technology in medical triage

Evaluating electronic medical record based screening protocol on hepatitis c screening and linkage to care

Background and Objectives: The Emergency Department (ED) is potentially a high-yield site in health care to reach patients at risk for the hepatitis C virus (HCV) infection, the most common chronic bloodborne pathogen in the United States. Of the 71 million HCV-infected individuals globally in 2017, only an estimated 19% were aware of their positive HCV status. If EDs can identify the infected patients, this is a step toward reducing new hepatitis infections and death due to HCV, goals set by the World Health Organization to be reached by 2030. The primary aim of this project is to determine the effectiveness of upgrading the laboratory infrastructure to enable routine HCV ribonucleic acid (RNA) reflex testing and determine its effect on linking patients to care. Methods: An automated HCV screening protocol was implemented into the EPIC electronic medical record (EMR). The system screens patients born from 1945 through 1965 and/or those with a history of intravenous drug use, two identified risk factors for HCV set by the Center for Disease Control and Prevention. A best practice advisory (BPA) notifies providers to order an HCV antibody (Ab) test for patients with an ordered complete blood count with at least one risk factor. Positive HCV Ab test triggers a second BPA, prompting a HCV RNA test. In January 2019, HCV RNA reflex testing began where the RNA test would be automatically ordered after a positive Ab result. Linkage to care team followed up with patients until they attended their first visit with a qualified provider. The data analysis is inclusive of data obtained between August 2018 and November 2019. Results: HCV Ab tests were performed on 9,704 patients. Prior to RNA reflex implementation, out of the 445 patients who tested positive for HCV Ab, 220 had HCV RNA test performed (49.4%). After the revised protocol, out of 671 patients who tested positive for HCV Ab, 601 had RNA test performed (90%). Before RNA reflex testing was initiated, 66 patients were linked to care versus 126 patients were linked to care after the implementation, an increase of 66%. Conclusion: A significantly higher percentage of patients with positive HCV Ab testing had HCV RNA tests completed after the implementation of routine HCV RNA reflex testing. Connection to care rates also increased. Overall, the utilization of BPA capability of an EMR system may be an invaluable tool in efforts to reduce the prevalence of HCV

A Pilot Trial of Topical Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome.

BACKGROUND: Patients with cannabinoid hyperemesis syndrome (CHS) present frequently to the emergency department. Previous case studies suggest dramatic symptomatic improvement with topical capsaicin treatment. This exploratory study examined the potential effectiveness of topical capsaicin in patients with nausea and vomiting due to a suspected CHS exacerbation. METHODS: This was a double-blind, randomized placebo-controlled pilot trial. Adults who presented with vomiting suspected to be from CHS were eligible for enrollment. We excluded pregnant women and those with resolution of symptoms. Following randomization, topical 0.1% capsaicin or placebo cream was applied to the anterior abdomen in a uniform manner. The primary outcome was the severity of nausea on a visual analog scale (VAS) of 0-10 cm assessed at 30 minutes. Secondary outcomes were adverse events, occurrence of post-treatment vomiting, nausea by VAS at 60 minutes, and hospital admission. RESULTS: This pilot trial enrolled 30 patients; 17 in the capsaicin arm and 13 in the placebo arm. One patient in the capsaicin arm did not tolerate treatment due to skin irritation. Mean nausea severity at 30 minutes was 4.1 ±2.3 cm in the capsaicin arm and 6.1 ±3.3 cm in the placebo arm (difference -2.0 cm, 95% CI, 0.2 to -4.2 cm). At 60 minutes, mean nausea severity was 3.2 ±3.2 cm versus 6.4 ±2.8 cm (difference -3.2 cm, 95% CI, -0.9 to -5.4 cm). The percent reduction in nausea at 60 minutes from baseline was 46.0% in the capsaicin arm and 24.9% in the placebo arm (difference 21.1%, 95% CI, -5.6% to 47.9%). A higher proportion of capsaicin group patients (29.4% vs. 0%) had complete resolution of nausea (RR 3.4, 95% CI, 1.6 to 7.1). CONCLUSION: In this pilot trial, the application of topical capsaicin cream was associated with a significant reduction in nausea at 60 minutes but not at 30 minutes and provided more complete relief of nausea