Journal articles: 'Previous ed' – Grafiati (2024)

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This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg–Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.

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Mucoceles are cysts that can develop after facial bone fractures, especially those involving the frontal sinuses. Despite being rare, mucoceles can result in serious delayed sequelae. We present a case of a frontal mucocele that developed two years after extensive facial trauma following a motor vehicle crash (MVC) and review the emergency department (ED) evaluation and treatment of mucocele. Early recognition, appropriate imaging, and an interdisciplinary approach are essential for managing these rare sequelae of facial trauma.

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ABSTRACT Background: Recently, many Canadian emergency departments (EDs) have struggled with physician staffing shortages. In 2006, the Ontario Ministry of Health and Long-Term Care funded a brief “emergency medicine primer” (EMP) course for family physicians to upgrade or refresh skills, with the goal of increasing their ED work intensity. We sought to determine the effect of the EMP on the ED work intensity of family physicians. Methods: A retrospective longitudinal study was conducted of the ED work of 239 family physicians in the 2 years before and after a minimum of 6 months and up to 2 years from completing an EMP course in 2006 to 2008 compared to non-EMP physicians. ED work intensity was defined as the number of ED shifts per month and the number of ED patients seen per month. We conducted two analyses: a before and after comparison of all EMP physicians and a matched cohort analysis matching each EMP physician to four non-EMP physicians on sex, year of medical school graduation, rurality, and pre-EMP ED work intensity. Results: Postcourse, EMP physicians worked 0.5 more ED shifts per month (13% increase, p = 0.027). Compared to their matched controls, EMP physicians worked 0.7 more shifts per month (13% increase, p = 0.0032) and saw 15 more patients per month (17% increase, p = 0.0008) compared to matched non-EMP physicians. The greatest increases were among EMP physicians who were younger, were urban, had previous ED experience, or worked in a high-volume ED. The effect of the EMP course was negligible for physicians with no previous ED experience or working in rural areas. Conclusion: The EMP course is associated with modest increases in ED work intensity among some family physicians, in particular younger physicians in urban areas. No increase was seen among physicians without previous ED experience or working in rural areas.

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BackgroundCo-morbidity is common among patients with eating disorders (ED) and some previous studies have reported a prevalence of over 80%. However, research in the area has been sparse and no previous studies include both children and adults, and both genders.MethodsData from the Stepwise quality control database, a large-scale Internet based data collection system for specialized ED care in Sweden, were used. The database includes data from children and adults and both genders. Stepwise contains structured diagnostic interviews for ED- and other DSM-IV Axis I diagnostics (the Structured Eating Disorder Interview and the M.I.N.I.Kid and SCID-I interviews). Part one is performed by trained staff and contains SEDI and SCID-I. Part two is made up of self-rating questionnaires and contains EDE-Q, and CPRS. The system is used in 32 treatment units (in and out patients) and comprises up to date1917 patients from all over Sweden.Results96,4% of the patients with ED was women and 3,6% were men. 74,8% of the patients with ED also had at least one other Axis I disorder. The most common type of diagnosis was anxiety (61%) followed by mood disorder (56%). 19% had substance use disorders. No gender differences regarding co-morbidity or specific ED diagnosis were observed.ConclusionThis study confirms previous results showing that the prevalence in co-morbidity is high among patients with ED. The high level of co-morbidity in patients with ED may change the approach in treatment and calls for more tailored treatment programs.

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<b><i>Introduction:</i></b> A history of transurethral surgery of the prostate is generally considered as a risk factor of adverse functional outcomes after radical prostatectomy (RP). We tested whether the risk of postoperative urinary incontinence (UIC) and erectile dysfunction (ED) after RP could be further substantiated in such patients. <b><i>Materials and Methods:</i></b> We tested the effect of the following variables on UIC and ED rates 1 year after RP: residual prostate volume after transurethral desobstruction, the time from transurethral desobstruction to RP, the type of transurethral desobstruction (TURP vs. laser enucleation), age, and nerve-sparing surgery (yes vs. no). UIC was defined as usage of any pad except a safety pad. ED was defined as no sexual intercourse possible. <b><i>Results:</i></b> Overall, 216 patients treated with RP between 2010 and 2019 in a tertiary care center were evaluated. All patients had previously undergone transurethral desobstruction. Regarding UIC analyses, only time from transurethral desobstruction to RP significantly influenced UIC rates (<i>p</i> = 0.003). Regarding ED rates, none of the tested variables reached statistical significance. <b><i>Conclusion:</i></b> The risk of UIC and ED after RP is substantial in men who had previously undergone transurethral desobstruction. The time from transurethral desobstruction to RP significantly impacts on the postoperative UIC rates. This observation should be further explored in future studies.

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Energy drinks (ED) are nonalcoholic beverages that have caffeine as their most common active substance. The rapid expansion of ED consumption has created concern in the scientific community as well as in the public opinion. We report a psychotic episode probably triggered by ED abuse in a young adult without previous psychotic disorders. We have reviewed the literature regarding the relationship between caffeine, energy drinks, and psychopathology. Few articles have been published about mental health effects of energy drinks and caffeine abuse. Nevertheless, this relationship has been suggested, specifically with anxiety disorders, manic episodes, suicide attempts, psychotic decompensation, and substance use disorder. ED consumption could represent a global public health problem because of the potential severe adverse effects in mental and physical health. To our knowledge, this article is probably the first case of psychosis related to ED abuse in an individual without previous psychotic disorders.

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Objectives: In this study, we aim to identify and discuss the clinical and demographic characteristics of previous emergency department (ED) patient visits, at one of the only two medical centers in Staten Island, the epicenter of the opioid epidemic within Staten Island, who subsequently present to the ED with an opioid overdose. Design: This was a retrospective, observational study of all patients presenting to the emergency ED between July 1, 2010 and December 31, 2015.Setting: The study was conducted at Staten Island University Hospital. The ED has a census of 120,000 patient visits per year.Patients: All adult patients ≥ 18 years of age, with an ICD-9 code consistent with opioid intoxication and a history of intentional or unintentional overdose were included.Main outcome measure: Clinical and demographic characteristics of previous ED patient visits who subsequently presented to the ED with an opioid overdose.Results: One hundred and twenty-four subjects with a median age of 30 years [interquartile range, 24-40] were reviewed. Eighty-seven (70 percent) were males. Fifty-five subjects were admitted, 68 discharged, and one death. Patients were not more likely to present at any specific time of day. The most common past medical history was anxiety (21 percent), depression (20 percent), back pain (15 percent), hypertension (14 percent), and seizure disorder (11 percent). The most common past surgical history was a prior orthopedic procedure (11 percent).Conclusions: This study identified clinical and demographic characteristics of previous ED patient visits who subsequently present to the ED with an opioid overdose. These characteristics will be vital toward an increased understanding of subjects who subsequently experience an opioid overdose.

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Production of verbs ending in -ed is among the most frequent challenges for learners of English. Literature shows that learners tend to use vowel epenthesis or -ed omission to produce these verbs. The present study investigated the production of English verbs ending in -ed by two speakers of Brazilian Portuguese, two of Spanish, two of German and two of English. Each participant individually audio-recorded 96 sentences with one verb in each of them, including 72 verbs ending in -ed and 24 irregular verbs, distractors in this study. The eight participants produced a total of 576 verbs with 25.52% of non-target productions, suggesting that these results were affected by participants’ proficiency, which seemed to be higher than the proficiency of participants from previous studies on verbs ending in -ed. Brazilian Portuguese and Spanish L1 speakers tended to use vowel epenthesis and -ed omission in verb production whereas German L1 speakers tended to use -ed omission, producing less marked syllable structures that are similar to their L1s’, following the tendency found in previous studies. Verb production was also influenced by change in the context preceding the -ed due to misreading, L1 and verb orthography. Production of verbs by English L1 speakers showed the -ed omission, which was possibly caused by blending and linking of similar sounds during the reading.

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Erectile dysfunction (ED) is the inability to achieve and maintain an erection. Erectile function is dependent upon complex interactions of neural and vascular pathways. A major neurotransmitter that facilitates erectile function is nitric oxide. Treatment of ED has expanded to include effective oral agents. Previous ED treatments have consisted of intracavernosal injection, transurethral dilators, and vascular constriction devices. Clinical management of ED will be presented with some discussion on the prostatectomy client.

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Introduction: Variations of patient volumes in the ED according to days of the week and month of the year are well-established. Anecdotally, ED volumes follow ‘waves’ that correlate with previous days. Time-series models have traditionally been used in econometrics to develop financial models, but have been adapted in other fields, such as health informatics. This study uses a time-series approach to assess whether these impressions are valid. Methods: The daily volume of patients presenting to four emergency departments (ED) at the Nova Scotia Health Authority from Jan 2010 to May 2015 were analyzed to assess for the effect of previous volumes on future volumes. Parameters were selected using the auto-correlation (ACF) and partial auto-correlation functions (PACF) for a Seasonal Auto-regressive Integrated Moving Average (SARIMA) model. The Box-Jenkins statistic was assessed for model suitability. To assess for accuracy, a forecast of the model was evaluated with a year of volumes set aside for testing. Results: The EDs saw an average of 365.1 patients per day, with a minimum of 188 patients and a maximum of 479. The increasing trend in volumes consistent with the increasing number of ED presentations nation-wide was detrended using linear regression. There was a significant correlation in ACF with the previous day (ρ1 = 0.297). A seasonal, periodic trend was seen weekly. Significant correlations occurred annually (ρ365 = 0.279) and at 29 days (ρ29 = 0.339), consistent with the lunar cycle. A seasonal model was postulated incorporating an auto-regressive (AR) coefficient, and a moving average (MA) coefficient for the previous day’s volume. An AR and MA seasonal coefficient were each incorporated using the weekly period. When using the model on the test data, the model predicted 4 more patient presentations on average than the true value, with 90% of the values within 37 presentations of the true volume. The Box-Jenkins statistic was non-significant, indicating no problems with model specification. Conclusion: The volume of patients presenting to an ED system is correlated with that of the previous day. A weekly seasonal variation was confirmed. Auto-correlations also occur annually and possibly associated with the lunar cycle. Previous ED volumes may be useful in forecasting patient volumes. The time-series approach may discover further ways to predict ED volumes.

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Introduction: Emergency department (ED) visits for mental health and addiction related complaints are common and appear to be increasing. It is believed these patients come to the ED requiring urgent assessment either because they do not have a primary care or psychiatric healthcare provider or access to their provider is not available in a timely fashion. The objective of this study was to describe healthcare utilization in the previous 12 months by patients presenting to the ED with a mental health complaint. Methods: Between April-November 2016, a convenience sample of adult (≥18 years) patients presenting to an academic ED (annual census 65,000) with a mental health and/or addictions complaint were invited to complete a paper-based survey to determine their usage of ten different mental healthcare resources over the previous 12 months. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 134 patients who completed the survey, mean (SD) age was 37.9 (15.7) years and 64 (47.8%) were male. Only 7 (5.2%) patients did not access any mental health resource in the previous 12 months, and the most commonly accessed resource was hospital EDs (102, 76.1%), with 24 (23.5%) of these patients using the ED at least 6 times. Patients also accessed a variety of other mental health resources, with 28 (20.9%) seeing their family physician, 20 (14.9%) seeing their psychiatrist/psychologist, and 61 (45.5%) seeing both in the previous 12 months. Only 6 (5.9%) patients used the ED exclusively for a mental health related complaint. By comparison, respondents accessed other specific mental health resources such as crisis centres (19, 14.2%), helplines (34, 25.4%), and peer-support groups (24, 17.9%) less often. Conclusion: These findings suggest that the ED is the most commonly used mental health resource for this population. However, these patients also frequently access family physicians and psychiatrists/psychologists, with community resources such as crisis centres, helplines, and peer-support being used less often. This suggests that lack of timely access to other mental health resources may be the primary motivation for accessing the ED.

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Abstract Background: Infections caused by resistant extended-spectrum beta-lactamase (ESBL)-producing enteric bacteria and their risk factors are globally recognized. However, such risk factors have not been explored in emergency department (ED) where the first choice of empirical antimicrobials is crucial. Objective: Determine risk factors of ESBL bacteremia in ED, especially in our geographic area. Methods: A retrospective case-double-control study was conducted at King Chulalongkorn Memorial Hospital. All adult ED patients with ESBL-producing E. coli and K. pneumoniae in blood cultures between October 2007 and October 2008 were recruited for this study. The potential risk factors were analyzed and compared with non- ESBL-producing bacteremic patients (control group 1) and matched general ED patients (control group 2). Nonbeta- lactam susceptibility testing among the cohort was also evaluated. Results: Thirty ESBL (cases), 103 group 1 controls, and 100 group 2 controls were assessed. Based on the univariate analysis, age, chronic kidney diseases, malignancy, poor functional status, previous hospitalization within 90 days, and previous antimicrobial exposure especially to cephalosporins, quinolones, and carbapenems within 30 days were the risk factors for ESBL bacteremia compared with both types of control patients. Age > 60 and previous cephalosporin use were consistently identified as the risk factors by multivariate models using both control groups. The susceptibility to non-beta-lactam agents in the ESBL group was significantly lower than the non-ESBL. No carbapenem resistance was found. Conclusion: Elderly ED patients, especially those who had previous cephalosporin exposure within 30 days, were at higher risk of ESBL-producing bacteremic infections. ESBLs tended to have less susceptibility to the non-β-lactam agents.

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Background: Social determinants of health (SDOH) are associated with a variety of health outcomes, yet their relation to emer­gency department (ED) visits among individu­als with coronary heart disease (CHD) or stroke is unclear.Objective: We examined whether SDOH were associated with ≥1 ED visit among persons diagnosed with CHD or stroke.Methods: We performed a cross-sectional analysis of the 2010-2018 National Health Interview Survey, examining ED visits among individuals who self-reported CHD or stroke diagnosis. The outcome was defined as re­porting ≥1 ED visit in the previous 12 months vs none. The SDOH examined were race, employment status, poverty, insurance status, marital status, and educational status.Results: We included N=14,925 partici­pants with a diagnosis of CHD or stroke. The mean (±SD) age was 68 (±.14) years. After adjusting for age and sex, non-Hispanic Blacks were more likely (adjusted odds ratio [AOR]: 1.29; 95%CI: 1.15-1.44) to report having ≥1 ED visits than Whites. Compared with Whites, Asians had lower odds of having ≥1 ED visit in the previous 12 months (AOR: .63, 95%CI: .49-.82). Those who were unmarried (AOR: 1.21, 95%CI: 1.12 – 1.31), unemployed (AOR: 1.53, 95%CI: 1.36- 1.72) and had a poverty income ratio of <1 (AOR: 1.47, 95%CI: 1.31-1.67) had higher odds of having ≥1 ED visits.Conclusion: Being Black, unmarried, unem­ployed, and having lower income levels were associated with a higher likelihood of having ≥1 ED visits in the prior 12 months among individuals with a CHD or stroke diagnosis. SDOH should be considered when devel­oping systematic interventions to prevent costly ED visits.Ethn Dis. 2021;31(1):41-46; doi:10.18865/ed.31.1.41

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The symmetry structures of the dimensionally reduced Einstein–Kalb–Ramond (EKR) theory is further studied. By using a so-called extended double (ED)-complex method, the usual Riemann–Hilbert (RH) problem is extended to an ED-complex formulation. A pair of ED RH transformations are constructed and they are verified to give infinite-dimensional double symmetry groups of the EKR theory, each of these symmetry groups has the structure of semidirect product of Kac–Moody group [Formula: see text] and Virasoro group. Moreover, the infinitesimal forms of these RH transformations are calculated out and they are found to give exactly the same results as previous, these demonstrate that the pair of ED RH transformations in this paper provide exponentiations of all the infinitesimal symmetries in our previous paper. The finite forms of symmetry transformations given in the present paper are more important and useful for theoretic studies and new solution generation, etc.

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Introduction:Clinicians working in emergency departments (ED) play a vital role in the healthcare response to chemical, biological, radiological, nuclear, and explosive (CBRNe) events. However, ED clinicians’ individual and workplace preparedness for CBRNe events is largely unknown.Aim:The aim of this research was to explore Australian ED nurses and doctors’ perceptions of individual and workplace preparedness related to CBRNe events.Methods:The study populations were Australian nurses and doctors who work in EDs. Data was collected via a survey with 43 questions requiring binary responses or a rating on a Likert scale. The survey consisted of questions relating to the participant’s previous disaster training, perceived likelihood of a CBRNe event impacting their ED, perceived level of knowledge, perceived personal preparedness, perception of ED preparedness, and willingness to attend their workplace. Data were analyzed using descriptive and inferential statistics.Results:There were 244 complete responses, 92 (37.7%) doctors and 152 (62.3%) nurses. When comparing doctors and nurses, there was a statistical difference between gender (p = < 0.001), length of employment (p = < 0.001), and role in the ED (p = < 0.001). Doctors and nurses had a similar level of previous training except for practical training in mask fitting (p = 0.033). CBRNe events were considered separately. Perceived level of knowledge, perceived personal preparedness, and perception of ED preparedness were significant predictors of willingness to work in all CBRNe event. Perceived likelihood of a CBRNe event impacting their ED was not a predictor of willingness.Discussion:This research contributes to an overview of the current status of Australian ED clinicians’ preparedness for CBRNe response. To increase the willingness of ED doctors and nurses attending their workplace for a CBRNe event, strategies should focus on enhancing individuals perceived level of knowledge, perceived personal preparedness, and perception of ED preparedness.

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Objectives. To identify the proportion of adult emergency department (ED) patients who screen positive for depression. Secondary aims were to identify factors associated with a positive depression screen and determine predictors of a positive depression screen. Methods. This cross-sectional, prevalence survey of ED patients was conducted at two inner-city hospitals. 350 ED patients were screened for depression using the Patient Health Questionnaire-9 (PHQ-9). Clinical and demographic risk factors were examined through medical records and additional questionnaires. Results. Of 350 participants screened, 50 (14.3%; 95% CI = 11.0–18.4%) screened positive. Independent predictors of depression risk included self-reported depression and/or a previous diagnosis of depression (OR = 8.345; 95% CI = 3.524–19.762), seeing a mental health service provider in the past 6 months (OR = 4.518; 95% CI = 2.107–9.690), and previous discussion about mental health with a local doctor (OR = 2.369; 95% CI = 1.025–5.475). Conclusion. ED patients were found to be at a higher risk of depression than the general population. ED-based depression screening, particularly of high-risk populations, has the potential to increase case detection rates and allow earlier management of these patients. Further research and validation of an ED-based depression screening tool are required.

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52 Background: Emergency department (ED) visits are a distressing event for patients with advanced cancer, and identifying planned, unplanned and avoidable ED visits is important for providing better cancer care. We studied the causes for ED visits, as well as potentially avoidable ED visits during palliative chemotherapy, among patients with advanced cancer treated at a public cancer center in Mexico City. Methods: Consecutive patients with newly diagnosed advanced solid tumors treated at Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán from 10/2015 to 03/2016 were screened. Patients who visited the ED during that period were included, and their demographic and clinical characteristics recorded. Number and reasons for ED visits were obtained from medical records. Among patients who received chemotherapy within the previous 30 days, the following reasons for ED visits were classified as avoidable: anemia, nausea, dehydration, neutropenia, diarrhea, pain, emesis, pneumonia, fever or sepsis (according to Centers for Medicare and Medicare Services Hospital Outpatient Quality Reporting Program). Results: 77 patients were diagnosed with advanced solid tumors during the study period, of which 53 (69%) had at least one ED visit. Median age was 63 years (range, 19-88), and 47% were men (n = 25). 51% had gastrointestinal, 21% genitourinary and 28% other tumors. Median follow-up was 360 days. 95 ED visits were identified; with a median number of ED visits per patient of 1 (range 1-5). The most common causes of ED visits were: infections (n = 20; 21%), gastrointestinal disorders (n = 18; 19%), pain (n = 15; 16%), ascites (n = 14; 15%), anemia (n = 4; 4%), catheter dysfunction (n = 4; 4%), and other causes (n = 20; 21%). 57% of ED visits among patients who received chemotherapy within the previous 30 days were classified as potentially avoidable. Conclusions: Over two thirds of patients with newly diagnosed metastatic cancer had ED visits in the first year after diagnosis. Furthermore, more than a half of ED visits among patients receiving palliative chemotherapy were potentially avoidable. Strategies aimed at reducing ED visits are needed to improve quality of care for patients with advanced cancer.

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Objectives. To define the prevalence and determinants of peripheral microvascular endothelial dysfunction (ED) in a large series of rheumatoid arthritis (RA) patients free of previous cardiovascular events. Materials and Methods. Data from 874 RA patients enrolled in the EDRA study (Endothelial Dysfunction Evaluation for Coronary Heart Disease Risk Estimation in Rheumatoid Arthritis—ClinicalTrials.gov: NCT02341066) were analyzed. Log-transformed reactive hyperemia index (Ln-RHI) was evaluated by peripheral arterial tonometry (PAT) using the EndoPAT2000 device: values of Ln-RHI < 0.51 were considered indicative of peripheral ED. Results. Peripheral microvascular ED was documented in one-third of RA patients (33.5%); in multiple logistic regression analysis, ACPA negativity and higher triglycerides concentrations were independently associated with the presence of peripheral ED [OR (95% CI) = 1.708 (1.218–2.396), p<0.01 and OR (95% CI) = 1.005 (1.002–1.009), p<0.01, respectively]. Multiple regression analysis showed a positive correlation between Ln-RHI values and systolic blood pressure and HDL cholesterol levels; furthermore, higher values of Ln-RHI were associated with ACPA positivity, while smoking habit was associated with lower Ln-RHI values. Conclusions. This study demonstrates for the first time a high prevalence of peripheral microvascular ED in patients with RA free of previous cardiovascular events that appear to be only partially driven by traditional cardiovascular risk factors. The association between ACPA negativity and ED warrants further exploration.

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Background/Aim. During the first 10 years over 50% of diabetes patients develop erectile dysfunction (ED). It is more severe and resistant to therapy than in male patients with normal glucoregulation. The purpose of this pilot study was to estimate the tadalafil (Cialis) efficacy and safety in male patients with diabetes mellitus (DM), together with moderate to severe ED. Methods. The study included 30 male patients with diagnozed type 1 or type 2 DM together with ED. ED was estimated through the International Index of Erectile Function (IIEF-6), Sexual Encounter Profile (SEP) questionnaire and prostaglandin test, at the beginning of the research and three months after the 20 mg tadalafil therapy initiation, once a week (on Fridays). Glycosylated haemoglobin in blood (HbA1c) values were also monitored. According to the ED severity (IIEF values at the beginning of the therapy) the patients were divided into 2 groups. The previous experience with sildenafil citrate (Viagra) and prostaglandin E1 intracavernous therapy was recorded. Results. Tadalafil significantly improved ED (p < 0.001) for 7.40 points of the IIEF score, i.e. for 58% and 60% towards SEP2 and SEP3 questionnaire, respectively. Compared to the previous ED therapy subjectively better tadalafil experience was recorded. Each group experienced a significant improvement in IIEF score (p < 0.001), more significantly in the group 2 (8.26?1.49 points) compared with the medium improvement in the group 1 (6.27?1.35 points). After three months HbA1c values decreased for 2.26?1.62 (p < 0.001). Conclusion. Tadalafil is an effective tool for treating ED in diabetes patients. In some situations tadalafil application could replace prostaglandin test. The sexual sphere motivation leads to the improvement of glucoregulation in DM patients. .

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We aimed to determine whether the Emergency Department (ED) is a suitable entrance point for osteoporosis screening among fallers without concomitant fracture compared to referral from general practice. Furthermore, to identify factors associated with osteoporosis among fallers.Methods. Patients aged 50–80 years sustaining a low-energy fall without fracture were identified from an ED (n=199). Patients answered a questionnaire on risk factors and underwent osteodensitometry. Data was compared to a group of patients routinely referred to osteodensitometry from general practice (n=201).Results. Among the 199 included fallers, 41 (21%) had osteoporosis. Among these, 35 (85%) reported either previous fracture or reduced body height (>3 cm). These two risk factors were more frequent among fallers with osteoporosis compared to fallers with normal bone mineral density or osteopenia (previous fractureP=.044, height reductionP=.0016). The osteoporosis frequency among fallers from ED did not differ from a similarly aged patient-group referred from general practice (P=.34).Conclusion. Osteodensitometry should be considered among fallers without fracture presenting in the ED, especially if the patient has a prior fracture or declined body height. Since fallers generally have higher fracture risk, the ED might serve as an additional entrance to osteodensitometry compared to referral from primary care.

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Background. Stroke is a leading cause of death and disability in developed countries. The major factor affecting long-term survival other than age is the disability severity caused by stroke. The modified Rankin Scale (mRS) is a global functional endpoint measurement used in acute stroke to evaluate the degree of disability or dependence in daily life activities. The objective of this study was to assess the effects of sociodemographic factors, concomitant disease states, and some measures performed in the emergency department (ED) on patients’ disability. Methods. We conducted a retrospective study on ischemic stroke patients admitted to Intensive Care Unit of three Lebanese university hospitals between June and December 2016. Patients were excluded if they had been discharged from ED without hospital admission or if mRS was not performed. The mRS was further subdivided into two categories considered as “good prognosis” (0-2 or 0-3) and “poor prognosis” (>2 or > 3). Results. 204 patients were included in the study with mean age of 65.4 ± 11.9 years, hypertension was the most previous concomitant past medical disease (77.1%), and 27.1% of these patients had previous history of stroke. No significant differences were found in both mRS categories for all sociodemographic factors, and past medical history except that arrhythmia was significantly more common in the higher mRS categories > 2 and > 3. Based on multivariable analysis, there was a trend for previous intake of calcium channel blocker to be associated with lower mRS at admission (beta -0.586). However, intracranial arterial stenosis, ED blood glucose > 180 mg/dL, and performing brain imaging above 20 minutes after patient presentation to ED were significantly associated with higher mRS scores at discharge with an ORa and (confidence interval) of 2.986 (0.814, 10.962), 3.301 (1.072, 1.261), and 1.138 (1.071, 9.080), respectively. Conclusion. mRS is affected by previous disease states, prescribed medications, and acute measures performed in ED. It is also influenced by intracranial arterial stenosis etiology, which is associated with worse outcome.

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Abstract Objectives Estimate the prevalence of eating disorders (ED) and their association with a previously suffered concussion among student-athletes at a Power Five conference university. Methods An observational, cross-sectional, and survey-based study was conducted among student-athletes of a Power Five conference university in Lubbock, Texas. Assessments of eating disorders were carried out using the Questionnaire for Eating Disorder Diagnoses (QEDD), which operationalizes ED criteria of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Questionnaires were administered via the web-based survey platform Qualtrics. A total of 413 student-athletes were eligible for the study. Results Final analysis included data from 158 student-athletes across 11 different sports disciplines. A total of 7 respondents (4.4%, 95% CI: 1.9%, 9.2%) met diagnostic criteria for ED: 6 cases of Eating Disorder Not Otherwise Specified (EDNOS) and 1 case of non-purging bulimia. A majority of cases of EDNOS were observed among student athletes participating in Track & Field (n = 4). Thirty-four respondents (21.5%, 95% CI: 15.5%, 28.9%) reported symptoms of ED but did not meet diagnostic criteria. Binging was the most prevalently reported symptom (n = 22, 65%). Statistical analysis of the incidence of ED and disordered eating among those with (n = 54), and without, a previous concussion demonstrated no significant difference (P = 1 and P = 0.7, respectively; Fisher's exact test). Conclusions An important prevalence of disordered eating behaviors seems to exist among this student-athlete population. However, no significant association with a previous concussion was found. Nonetheless, such results warrant for the implementation of effective screening measures and interventions for ED and associated symptoms considering their potential adverse effects on student-athletes’ long-term physical and mental health. Funding Sources Texas Tech University.

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Distance patients have to travel has shown to influence demand for several health services. Our work looks at this effect on the utilization of Emergency Departments (ED) in Portugal. We build upon previous works by taking into account both the severity of emergency visits and the type of ED and by including a set of other variables that have shown to influence ED utilization. Overall, we find distance-elasticity for emergency care that ranges from -1 to -2 (a 10% increase in distance to ED results in a 10-20% decrease in ED utilization), with low-severity demand having the highest distance-elasticity and high-severity demand the lowest. We also show that Primary Health Care, and particularly some new typology of health centers in Portugal, negatively affects ED utilization. Our results provide evidence that distance enters in the budget constraints patients face when seeking health care.

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Eating disorders (EDs) are stereotypically associated with thin, White, affluent women and girls. One result of the ED stereotype has been a relative dearth of ED research with marginalized communities. The aim of this study was to replicate recent findings showing an association between the severity of food insecurity (FI) and increased ED pathology. Participants included 891 clients of an urban food bank. Results were consistent with the findings of previous research; participants in the most severe FI group reported significantly higher levels of ED pathology, dietary restraint, anxiety, and depression. Findings provide further evidence that the thin, White, affluent, female ED stereotype offers a flawed portrait and highlight the need for additional psychological research that focuses on marginalized populations to address disparities in access to care. Both scholars and clinicians need to move away from the stereotypical portrait of who is and is not at risk for developing an ED.

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Discourse in popular media, public policy, and academic literature contends that people who are homeless frequently make inappropriate use of hospital emergency department (ED) services. Although researchers have investigated the ED experiences of people who are homeless, no previous studies have examined how this population understands the role of the ED in their health care and in their day-to-day lives. In the present study, 16 individuals participated in semistructured interviews regarding their ED experiences, and narrative analysis was applied to their responses. Within the context of narratives of disempowerment and discrimination, participants viewed the ED in differing ways, but they generally interpreted it as a public, accessible space where they could exert agency. ED narratives were also paradoxical, depicting it as a fixed place for transient care, or a place where they were isolated yet felt a sense of belonging. Implications for policy and practice are discussed.

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Previous studies have suggested that oxidative stress may heighten atherosclerotic burden in rheumatoid arthritis (RA), but direct evidence is lacking. Objective: To evaluate the relationship between established plasma oxidative stress biomarkers and peripheral endothelial dysfunction (ED), a marker of early atherosclerosis, in RA. Methods: Paroxonase-1 (PON-1), protein-SH (PSH), and malondialdehyde (MDA) were measured in 164 RA patient s and 100 age- and sex-matched healthy controls without previous cardiovascular events. Peripheral ED, evaluated by flow-mediated pulse amplitude tonometry, was defined by log-transformed reactive hyperemia index (Ln-RHI) values < 0.51. Results: PON-1 activity and PSH concentrations were significantly reduced in RA patients compared to controls. In regression analysis, increased plasma MDA levels were significantly associated with reduced Ln-RHI [B coefficient (95% CI) = −0.003 (−0.005 to −0.0008), p = 0.008] and the presence of peripheral ED (OR (95% CI) = 1.75 (1.06–2.88), p = 0.028). Contrary to our expectations, increased PON-1 activity was significantly associated, albeit weakly, with the presence of ED (OR (95% CI) = 1.00 (1.00–1.01), p = 0.017). Conclusions: In this first evidence of a link between oxidative stress and markers of atherosclerosis, MDA and PON-1 showed opposite associations with peripheral vasodilatory capacity and the presence of ED in RA. Further studies are needed to determine whether this association predicts atherosclerotic events in the RA population.

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Background The present study builds on previous research which explored the relationship between mentalizing and eating disorders (ED) in a subgroup of patients with comorbid self-harm (SH). Whereas previous literature had linked this comorbidity to impulse-control difficulties, more recent advances have suggested that a lack of a mentalizing stance might be responsible for a more treatment-resistant and severe symptomatology in this subgroup of clients. Methods A cross-sectional, quasi-experimental, questionnaire-based, between-groups design was employed and a measure of mentalizing was compared in individuals presenting with ED only, individuals presenting with ED and concurrent SH and a control group. Results Individuals with ED with concurrent SH reported significantly more mentalizing ability impairment than individuals without concurrent SH. In addition, both groups differed significantly from the control group. Opposite scoring patterns were identified in hypo- and hypermentalizing with the comorbid group reporting the lowest scores in hypermentalizing and the highest scores in hypomentalizing. Conclusions The current findings confirm that individuals with concurrent ED and SH report more severe impairments in mentalizing ability. Such impairments entail difficulties in symbolic capacity and abstract thinking and a concretisation of inner life, exemplified by a rigid, often inflexible focus on the physical world. The clinical implications that a lack of a mentalizing stance can have on individuals’ ability to engage with the therapeutic process and to initiate change are reflected upon.

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The overwhelming majority of the research on the historical impact of IQ in special education has focused on children with cognitive disorders. Far less is known about its role for students with emotional concerns, including Emotional Disturbance (ED). To address this gap, the current study examined IQ trends in ED children who were repeatedly tested on various combinations of the WISC, WISC-R, and WISC-III using a geographically diverse, longitudinal database of special education evaluation records. Findings on test/re-test data revealed that ED children experienced IQ trends that were consistent with previous research on the Flynn effect in the general population. Unlike findings associated with test/re-test data for children diagnosed with cognitive disorders, however, ED re-diagnoses were unaffected by these trends. Specifically, ED children’s declining IQ scores when retested on newer norms did not result in changes in their ED diagnosis. The implications of this unexpected finding are discussed within the broader context of intelligence testing and special education policies.

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Introduction: Despite being legal in Canada, the vaporized liquid of vaping systems contains several chemicals presenting unknown risks to lung health and little is known about their use in patients visiting the emergency department (ED). This study explores associations between exposure to inhaled products and respiratory presentations in the ED. Methods: A cross-sectional lung health survey among patients presenting to a Canadian ED was conducted, exploring the association between inhaled toxic exposures (e.g., vaping, cannabis and cigarette smoking) and visits related to respiratory symptoms. Eligible participants were ambulatory (CTAS 2 to 5), stable, adults (≥ 17 years) visiting the ED from July to November, 2019. Results are described as frequencies and percentages (categorical variables) and medians with interquartile range (IQR, continuous variables). Univariate and multivariate logistic regression models report associations as odds ratios (OR) with 95% confidence intervals (CIs). The Health Research Ethics Board approved the study. Results: From 1433 eligible patients, 1024 (71%) completed the survey. The median age was 43.5 (IQR: 29, 60), and 51% were female. Overall, 177 (17%) reported ≥1 respiratory symptoms and 83 (8%) reported using any vaping products. In a univariate regression analysis, exposure to vaping was positively associated with ED visits related to respiratory symptoms (OR 2.11, 95% CI: 1.26 to 3.54). In the multivariate model, vaping and a previous diagnosis of ≥1 respiratory conditions showed positive association with respiratory-related ED visits (OR 1.86, 95% CI: 1.03 to 3.33; and OR 2.13, 95% CI: 1.50 to 3.02, respectively). There was evidence of an additive effect of the combined exposure to cigarettes and vaping and respiratory-related ED visits (OR 3.22, 95% CI: 1.61 to 6.43). Smoking cannabis and cigarettes alone were not associated with increased risk of respiratory-related visits. Conclusion: Using vaping products increased the occurrence of respiratory-related ED visits, particularly in people with pre-existing lung conditions. A dose-response relationship exists where the risk is highest in patients inhaling a combination of toxins. Contrary to previous assumptions, the use of vaping products has a negative impact on lung health.

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Pelvic congestion syndrome (PCS) is an uncommon illness that is typically diagnosed after chronic pelvic pain. We present a case of superficial thrombosis of pelvic veins from PCS that presented to the emergency department (ED) as a previous diagnosis of pelvic abscess with cellulitis. PCS was diagnosed in the ED by computed tomography after an abnormal point-of-care ultrasound. Here we describe this unusual presentation and our approach to the diagnosis.

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AbstractObjectiveTo determine whether a nursing intervention delivered at emergency department (ED) discharge would reduce ED revisits.MethodA randomized study was conducted in the ED of a tertiary cardiac hospital in Montreal, Quebec. Between November 2006 and March 2010, 3,795 patients were assessed for eligibility based on two risk factors for ED revisits (≥1 ED visit in the past year and ≥6 medications); 132 were randomized to the experimental group (EG) and 133 to the control group (CG). The intervention included one nurse-patient meeting before leaving the ED, with two additional telephone contacts over the next 2 weeks. The primary outcome was time to ED revisits within 30 days after discharge. Secondary outcomes included time to ED revisits over 90, 180, and 365 days and hospitalizations over 30, 90, 180, and 365 days.ResultsA planned interim analysis that stopped the study with half of the planned sample showed that the time to ED revisits was similar in both groups at 30 days (p=0.81; revisits: 18.2% in EG, 19.6% in CG), 90 days (p=0.44), 180 days (p=0.98), and 365 days (p=0.75). The only difference identified was a lower hospitalization proportion at 180 days in the EG group (13.6% v. 24.1%; p=0.038).ConclusionsThese findings are consistent with previous research showing that few ED-based interventions are successful in reducing ED returns. Factors other than those targeted by the intervention, including an improvement in usual care, may explain the findings.

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Introduction: The number of CT scans prescribed in the Emergency department (ED) for suspected renal colic has increased over recent years without an associated improvement in patient-centred outcomes. We assessed whether Point-of-Care Ultrasound (PoCUS) decreases the use of formal radiologic imaging. Methods: We completed a retrospective cohort study on consecutive patients 18 years of age and older presenting to the ED with suspected uncomplicated renal colic in a tertiary care centre in Québec in 2016. Exclusion criteria included: previous urologic intervention, solitary kidney, dialysis, fever, pyuria, acute kidney injury, pregnancy, suspicion of a serious alternative diagnosis or persistent symptoms despite analgesia. We compared the proportion (95%CI) of formal radiologic imaging performed (Ultrasound or CT) in patients who had PoCUS in the ED vs. those who did not. Two-tailed Fisher exact test (α = 0.05) and odds ratios (95%CI) calculated from multivariate logistic regression models adjusted for age, gender, Charlson Index and previous renal colic were used to compare the two groups. The reliability of data collection was evaluated with a kappa score (95%CI). Results: 169 patients with uncomplicated renal colic were included. There was no difference between the groups in terms of age, gender, Charlson Index, or previous renal colic. The PoCUS level of training and the doctor's education level was significantly higher in the PoCUS group. There was a non-significant trend towards less formal imaging in patients of the PoCUS group 65/88 (73.9% [63.4-82.7%]) vs. the non-PoCUS group 69/81 (85.2% [75.6-92.1%]), p = 0.087. After adjustment for confounders, the patients not evaluated with PoCUS were more likely to have formal imaging with a significant odds ratio of 2.41 [1.05-5.56]). Among patients who underwent a CT, incidentalomas were found in 16.5% and only 2.0% demonstrated significant findings leading to changes in ED management, such as an alternative diagnosis, need for admission, or an urgent urological intervention. Inter-observer agreement was excellent between assessers with a kappa score of 0.88 [0.66-1.00]. Conclusion: ED patients with uncomplicated renal colic who are investigated with PoCUS tend to have fewer formal imaging test. When CT scans were performed, incidentalomas were found in 16.5% and ED management changed only 2.0% of the time. PoCUS appears to be a useful tool for decreasing CT utilisation in this low-risk ED population.

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Introduction: Atrial fibrillation and flutter (AF/AFL) are the most common arrhythmias encountered in the emergency department (ED); however, little information exists regarding the preventive management of patients with AF/AFL by emergency physicians (EPs). This study explored whether patients with AF/AFL received the recommended thrombo-embolic (TE) prophylaxis at discharge from the ED; patients’ TE risks, bleeding risks, and TE prophylaxis upon discharge from the ED were examined following assessment for symptomatic acute AF/AFL. Methods: Patients ≥18 years of age identified by the EP as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three urban Canadian EDs. Using standardized patient enrollment forms, trained research assistants collected data on the patient’s demographics, TE risk (using the CHADS2 and CHA2DS2-VASc score), bleeding risk (using the HAS-BLED score), and management both in the ED and at discharge. Treating physicians were surveyed on their use of risk scores when making TE prophylaxis decisions as well as their estimate of the patient’s stroke and bleeding risk. Descriptive analyses were performed. Results: From a total of 196 patients, 62% were male and the mean age was 63 years (standard deviation [SD] ±14). Most patients had previous history of AF/AFL (71%); hypertension was documented in 40% of them and ≤10% had other risk factors (e.g., congestive heart failure, vascular disease, diabetes, previous stroke, transient ischemic attack). Based on the CHADS2 score and previous management, there was opportunity for new or revised antiplatelet/anticoagulant treatment by EPs in 19% of the patients. Consultations were requested in 28% of the patients, and the majority (89%) were discharged with anticoagulant or antiplatelet agents. EPs expressed concerns that an increased risk of falls, lack of access to facilities for INR monitoring, and significant cognitive impairment would affect their willingness to prescribe anticoagulation. Conclusion: Most patients in the ED with acute AF/AFL are receiving the recommended TE prophylaxis; however, given the significant morbidity and mortality associated with AF/AFL, improved short-term prescribing practices for anticoagulants would benefit 1 in 5 ED patients. More research on barriers to EPs prescribing anticoagulants is required to improve clinician comfort in treating this high-risk population.

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ABSTRACTObjectivesSubstance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED.MethodsThis prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available.ResultsWe received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated “Yes” for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period.ConclusionsAt least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.

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Introduction: Excessive use of the emergency department (ED) is a major source of healthcare expenditure. ED frequent users, have been identified as a major contributing factor to a disporportionate amount of ED visits and costs, making up 20% to 30% of all annual visits. The aim of the study was to identify risk factors that place adults age 55 and older at risk for frequent ED use.Methods: The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults was used to identify risk factors for frequent use of ED services in adults 55 and older.Results and conclusions: A third of the sample (33%) had active behavioral and/or psychiatric issues. A majority of the sample (87%) had two or more hospitalizations within 6 months of a prior ED visit, and seventy-two percent were hospitalized within thirty days of an Emergency Department visit. Almost 70% had at least 1 chronic diagnosis of diabetes (41.5%), heart failure (35.8%), or COPD (28%). Most patients were between ages 70-85 years old and risk factors for ED frequent use included 4 or more coexisting health conditions, 6 or more prescription medications, previous hospital admissions, active behavioral and/or psychiatric issues. Identifying older adults at high risk for ED frequent use may provide earlier interventions and less reliance on ED use for care and treatment of chronic disorders.

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Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures &amp; Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.

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Introduction Research has shown that during the 2003 SARS pandemic, emergency department (ED) visits among the pediatric population decreased. We set out to investigate if this was also true for injury-related ED visits during the COVID-19 pandemic. Methods Using data from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), we looked at 28 years of injury-related ED visits at the Montreal Children’s Hospital, a provincially designated Pediatric Trauma Centre. We compared data from a two-month period during the COVID-19 lockdown (16 March to 15 May) to the same period in previous years (1993–2019) to determine whether the 2020 decrease in ED visit numbers was unprecedented (i.e. a similar decrease had never occurred) for different age groups, nature of injuries, mechanisms and severity. Results The 2020 decrease was unprecedented across all age groups between 1993 and 2019. When compared with the 2015 to 2019 average, the decrease was smallest in children aged 2 to 5 years (a 35% decrease), and greatest in the group aged 12 to 17 years (83%). Motor vehicle collisions and sports-related injuries practically vanished during the COVID-19 lockdown. Surprisingly, more children aged 6 to 17 years presented with less urgent injuries during the COVID-19 lockdown than in previous years. Conclusion As was the case with SARS in 2003, COVID-19 acted as a deterrent for pediatric ED visits. The lockdown in particular had a profound impact on injury-related visits. The de-confinement period will be monitored to determine the impact in both the short and the long term.

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Introduction: Hypertension is common and a major cause of morbidity and mortality. Because it is asymptomatic, its diagnosis is often delayed. For many Canadians the Emergency Department (ED) is the only point of entry to the health care system, and therefore the recognition of undiagnosed and untreated hypertension in the ED is increasingly important. This study sought to evaluate the prevalence and severity of hypertension in patients presenting to Calgary area EDs, as well as to determine whether medical therapy was initiated and if patients had primary care providers for follow-up. Methods: Multi-centre electronic medical record (EMR) review of all adult patients presenting to Calgary area EDs from January 1, 2016 to December 31st, 2016. Hypertension was coded electronically by triage nurses and defined as systolic blood pressure SBP 140 mmHg and/or diastolic blood pressure DBP 90 mmHg. Hypertensive urgency was defined as SBP 180 mmHg and/or DBP 120 mmHg. Descriptive data was used to show patient demographics and hypertension prevalence. Primary care provider status, previous diagnosis of hypertension, chief complaint, and ED diagnoses were extracted and the EMRs were manually searched to determine whether treatment was initiated in the ED. Results: Of 304392 patients presenting to all Calgary sites, 43055 (14%) were found to have hypertension; mean age 52 (range 18 to 104), female 42%. Of these, 32986 (77%) had no known previous hypertension and 31% lacked a primary care provider. 0.2% had documentation of treatment initiated in the ED. 16% met criteria for hypertensive urgency. Conclusion: Many patients presenting to the ED have hypertension, often previously undiagnosed and at times severe. Many lack access to primary care. EDs may play an important role in the early recognition of hypertension. Dedicated management and follow-up pathways are indicated for this high-risk population.

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Introduction: Although oral rehydration therapy is recommended for children with acute gastroenteritis (AGE) with none to some dehydration, intravenous (IV) rehydration is still commonly administered to these children in high-income countries. IV rehydration is associated with pain, anxiety, and emergency department (ED) revisits in children with AGE. A better understanding of the factors associated with IV rehydration is needed to inform knowledge translation strategies. Methods: This was a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) randomized, controlled trials of oral probiotics in children with AGE-associated diarrhea. Eligible children were aged 3-48 months and reported &gt; 3 watery stools in a 24-hour period. The primary outcome was administration of IV rehydration at the index ED visit. We used mixed-effects logistic regression model to explore univariable and multivariable relationships between IV rehydration and a priori risk factors. Results: From the parent study sample of 1848 participants, 1846 had data available for analysis: mean (SD) age of 19.1 ± 11.4 months, 45.4% females. 70.2% (1292/1840) vomited within 24 hours of the index ED visit and 34.1% (629/1846) received ondansetron in the ED. 13.0% (240/1846) were administered IV rehydration at the index ED visit, and 3.6% (67/1842) were hospitalized. Multivariable predictors of IV rehydration were Clinical Dehydration Scale (CDS) score [compared to none: mild to moderate (OR: 8.1, CI: 5.5-11.8); severe (OR: 45.9, 95% CI: 20.1-104.7), P &lt; 0.001], ondansetron in the ED (OR: 1.8, CI: 1.2-2.6, P = 0.003), previous healthcare visit for the same illness [compared to no prior visit: prior visit with no IV (OR: 1.9, 95% CI: 1.3-2.9); prior visit with IV (OR: 10.5, 95% CI: 3.2-34.8), P &lt; 0.001], and country [compared to Canada: US (OR: 4.1, CI: 2.3-7.4, P &lt; 0.001]. Significantly more participants returned to the ED with symptoms of AGE within 3 days if IV fluids were administered at the index visit [30/224 (13.4%) versus 88/1453 (6.1%), P &lt; 0.001]. Conclusion: Higher CDS scores, antiemetic use, previous healthcare visits and country were independent predictors of IV rehydration which was also associated with increased ED revisits. Knowledge translation focused on optimizing the use of antiemetics (i.e. for those with dehydration) and reducing the geographic variation in IV rehydration use may improve the ED experience and reduce ED-revisits.

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Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the most common related to team cognition. We conducted interviews with 18 healthcare professionals to better understand how work system design influences team cognition barriers and facilitators. Using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling, we identified when each barrier/facilitator occurred. The ED to OR transition had more barriers in transition preparation, while OR to PICU had more facilitators in the transition. Future research should explore solutions to support team cognition early in the ED to OR transition, such as designing a technology to be used by distributed teams.

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2042 Background: Lung cancer patients commonly need unplanned visits to ED. Many of these visits could be potentially avoidable if it were possible to identify patients at risk when the previous scheduled visit takes place. At that moment, it would be possible to perform elective actions to manage patients at risk to consult the ED in the near future. Methods: Unplanned visits of patients in active cancer therapy (i.e. chemo or immunotherapy) are attended in our own ED facilities. Our Electronic Health Record (EHR) includes specific modules for first visit, scheduled visits and unplanned visits. Lung cancer patients with at least two visits were eligible. The event of interest was patient visit to ED within 21 or 28 days (d) from previous visit. Free text data collected in the three modules were obtained from EHR in order to generate a feature vector composed of the word frequencies for each visit. We evaluate five different machine learning algorithms to predict the event of interest. Area under the ROC curve (AUC), F1 (harmonic mean of precision and recall), True Positive Rate (TPR) and True Negative Rate (TNR) were assessed using 10-fold cross validation. Results: 2,682 lung cancer patients treated between March 2009 and October 2019 were included from which 819 patients were attended at ED. There were 2,237 first visits, 47,465 scheduled visits (per patient: range 1-174; median 12) and 2,125 unplanned visits (per patient: range 1-20; median 2). Mean age at diagnosis was 64 years. The majority of patients had late stage disease (34.24 % III, 51.56 % IV). The Adaptive Boosting Model yields the best results for both 21 d or 28 d prediction. Conclusions: Using unstructured data from real-world EHR enables the possibility to build an accurate predictive model of unplanned visit to an ED within the 21 or 28 following d after a scheduled visit. Such utility would be very useful in order to prevent ED visits related with cancer symptoms and to improve patients care. [Table: see text]

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173 Background: Visits to the emergency department (ED) are common among patients with cancer (PWCs). Previous research suggests that few ED visits are precipitated by true oncologic emergencies (Diaz-Couselo 2004). Designing initiatives to reduce ED visits requires a rich understanding of factors that drive PWCs to visit the ED. Methods: Standardized interviews were conducted with 12 oncology clinicians at an academic oncology clinic in Toronto, Canada. Interviews were also conducted with 10 PWCs. Interviews explored factors that may drive ED visits, and interviewees’ insights into interventions to prevent ED visits. Interviews were audio recorded and transcribed. Transcriptions were qualitatively analyzed by two independent reviewers using the constant comparison method (Strauss and Corbin 1998). Results: Ten themes were identified as factors that may drive ED visits, with little overlap between themes identified by clinicians versus those identified by PWCs. Clinicians identified low socioeconomic status, lack of social support, advanced age, comorbidities, anxiety and non-adherence as important factors. In contrast, PWCs focused on the severity and expectedness of symptoms, lack of access to afterhours oncology advice and care, and adherence with medical and non-medical advice as drivers of ED visits. Regarding potential interventions, there was broad agreement between clinicians and PWCs regarding what might be helpful. Both groups identified improved access to expert cancer advice/care, improved coordination of care between clinics and ancillary health services, and patient education as important interventions. Clinicians also believed increasing community supports would help prevent ED visits. PWCs emphasized that some ED visits are not preventable. Conclusions: Clinicians and PWCs have different views on what drives ED visits. Despite identifying different drivers, clinicians and PWCs identified common solutions for reducing ED visits.

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BackgroundInterruptions are endemic in healthcare work environments. Yet, they can have positive effects in some instances and negative in others, with their net effect on quality of care still poorly understood. We aimed to distinguish beneficial and detrimental forms of interruptions of emergency department (ED) providers using patients’ perceptions of ED care as a quality measure.MethodsAn observational design was established. The study setting was an interdisciplinary ED of an academic tertiary referral hospital. Frequencies of interruption sources and contents were identified in systematic expert observations of ED physicians and nurses. Concurrently, patients rated overall quality of care, ED organisation, patient information and waiting times using a standardised survey. Associations were assessed with hierarchical linear models controlling for daily ED workload. Regression results were adjusted for multiple testing. Additionally, analyses were computed for ED physicians and nurses, separately.ResultsOn 40 days, 160 expert observation sessions were conducted. 1418 patients were surveyed. Frequent interruptions initiated by patients were associated with higher overall quality of care and ED organisation. Interruptions relating to coordination activities were associated with improved ratings of ED waiting times. However, interruptions containing information on previous cases were associated with inferior ratings of ED organisation. Specifically for nurses, overall interruptions were associated with superior patient reports of waiting time.ConclusionsProvider interruptions were differentially associated with patient perceptions of care. Whereas coordination-related and patient-initiated interruptions were beneficial to patient-perceived efficiency of ED operations, interruptions due to case-irrelevant communication were related to inferior patient ratings of ED organisation. The design of resilient healthcare systems requires a thorough consideration of beneficial and harmful effects of interruptions on providers’ workflows and patient safety.

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This article presents a reading of Douglas Coupland’s 2000 novel Miss Wyoming. Long before this novel was published Coupland had denounced the Generation X phenomena he had started in the early nineties, and this article examines Miss Wyoming’s intertextual references to Jack Kerouac as a representative of the Beat generation, which was the previous self-labeled literary generation in North America before the Generation X of the 1990s. Taking this relationship as a point of departure, the article also explores the novel’s relationship with the Bildungsroman, and it is suggested that the novel portrays communicative and emotional immaturity especially in relation to ideas of postmodernism and irony.

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Introduction: The epidemiology of Emergency Department (ED) visits provides important data regarding demand for the medical resources. The aim: To present changes in the visits to ED of University Hospital during the early stage of Covid-19 state of epidemic. Matrial and Methods: All ED visits during the 3 periods each lasting one weeks in 2018, 2019, and 2020 respectively were analysed. The data related to patients ’visits in the emergency department were gathered. Results: The percentage of patients admitted between 23-29.03 in 2020 year was 23.7% of the study group and constituted a significantly lower percentage than those admitted in 2028 who constituted 37.2% and 2019 who constituted 39.1% p<0.001. There was no significant differences between percentages of patients admitted to ED and brought by EMS among studied periods. The percentage of patients admitted to other ward of the hospital was higher in 2020 than in 2018 and 2019. Conclusions: 1. During early stage of COVID-19 epidemic state the number of ED significantly decreased both patients brought by EMS and non EMS pathway. 2. Patients admitted to ED are more often admitted to other ward of the hospital. 3. The mortality during ED stay is similar than in similar periods in previous years.

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Objective: Patient satisfaction, an indicator of the quality of care provided by emergency department (ED) personnel, is a significant issue for EDs. The purpose of this study was to identify factors associated with patient satisfaction and dissatisfaction, and to describe demographic characteristics of those surveyed in a university hospital ED. Methods: All adult patients who consecutively presented to the ED between 8:00 a.m. and 5:00 p.m. on weekdays were included in the study. Patients were asked to complete a questionnaire prior to discharge. The questionnaire asked about the attitude, politeness, and efficiency of the medical and ancillary staff, the reason for preferring our centre and reasons for dissatisfaction. Results: Two-hundred and forty-five adult patients presenting to our ED were included in this study. Forty-five percent of patients preferred our ED because of the previous perception of higher quality of care, informed by other people previously treated in this ED unit, and 35% because of restrictions by their health insurance carrier. The main causes of patient dissatisfaction were lengthy waiting times (27%). Conclusion: As a result, lengthy waiting time was the major reason for patient dissatisfaction, and high quality care together with insurance restrictions were the main reasons for preference of this university hospital ED.

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Background. To differentiate acute coronary syndrome (ACS) from other causes in patients presenting with chest pain at the emergency department (ED) is crucial and can be performed by the nurse triage. We evaluated the effectiveness of the ED nurse triage for ACS of the tertiary care hospital.Methods. We retrospectively enrolled consecutive patients who were identified as ACS at risk patients by the ED nurse triage. Patients were categorized as ACS and non-ACS group by the final diagnosis. Multivariate logistic analysis was used to predict factors associated with ACS. An online model predictive of ACS for the ED nurse triage was constructed.Results. There were 175 patients who met the study criteria. Of those, 28 patients (16.0%) were diagnosed with ACS. Patients with diabetes, patients with previous history of CAD, and those who had at least one character of ACS chest pain were independently associated with having ACS by multivariate logistic regression. The adjusted odds ratios (95% confidence interval) were 4.220 (1.445, 12.327), 3.333 (1.040, 10.684), and 12.539 (3.876, 40.567), respectively.Conclusions. The effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals.