Impact of the COVID pandemic on emergency department CT utilization: where do we go from here?

PURPOSE: To analyze the impact of the coronavirus disease (COVID) pandemic on emergency department (ED) computed tomography (CT) utilization. METHODS: A retrospective observational study was conducted assessing seven hospitals' ED imaging volumes between Jan. 6, 2019, and Feb. 27, 2021. Weekly CT utilization is reported as CTs ordered per 100 ED visits. Utilization was ascertained in aggregate and by body area. Interrupted time series analysis was performed to assess significance of utilization change. Prespecified sensitivity analysis was performed for influenza-like or COVID-like illness (ILI/CLI). RESULTS: Weekly ED CT utilization increased from 35.9 CTs per 100 visits (95% confidence interval [95% CI] 35.8-36.1) to 41.8 per 100 visits (95% CI 41.7-42.0) in pre- and post-pandemic periods. Weekly ED CT chest utilization increased immediately following the pandemic declaration (+ 0.52 chest CTs per 100 ED visits, 95% CI 0.01-1.03, p < 0.05) and compared to pre-pandemic period (+ 0.02 per 100 ED visits, 95% CI 0.02-0.05, p < 0.02). For both CT abdomen/pelvis and CT head, there was neither an immediate effect (+ 0.34 CT-AP per 100 ED visits, 95% CI - 0.74 to 1.44, p = 0.89; - 0.42 CT-H per 100 ED visits, 95% CI - 1.53 to 0.70, p = 0.46) nor a change in weekly CT utilization (+ 0.03 CT-AP per 100 ED visits, 95% CI - 0.01 to 0.05, p = 0.09; + 0.03 CT-H per 100 ED visits, 95% CI - 0.01 to 0.06, p = 0.10).  CONCLUSION: These data may help formulate future strategies for resource utilization and imaging operations as we envision a future with COVID and other federal mandates affecting imaging utilization and appropriateness.

Opioid-related Emergency Department Visits During COVID-19 in a Large Health System.

OBJECTIVE: Multiple states have reported increases in opioid overdose deaths during the coronavirus disease 2019 (COVID-19) pandemic, however little is known about opioid-related presentations to the emergency department (ED). METHODS: This was a time series analysis of visits to 7 EDs in greater Chicago, Illinois from October 20, 2019 to July 25, 2020. We compared the number of ED visits for opioid-related diagnoses in the time period preceding the World Health Organization pandemic declaration (prepandemic period, October 20, 2019-July 3, 2020) to the time period following the World Health Organization declaration (pandemic period, March 8, 2020 to July 25, 2020) using a single-group interrupted time series analysis with Newey-West standard errors. We also present data on alcohol-related ED visits for comparison. RESULTS: We evaluated a total of 177,405 visits across the 7 EDs during the study period. The mean number of weekly ED visits in the prepandemic and pandemic periods was 4841 and 4029 weekly visits, respectively. In the interrupted time series analysis, there was no significant immediate effect of the pandemic start on opioid-related ED visits (-0.44 visits per 1000 ED visits, 95% CI -2.47 to 1.58, P = 0.66), however, there was a significant immediate effect of the pandemic start on alcohol-related ED visits (-4.1, 95% CI: -8.25 to -0.01, P < 0.05). CONCLUSIONS: Despite reductions in overall ED visit volumes and alcohol-related visits during COVID-19, the number of opioid-related visits was not significantly reduced during the early pandemic. These data reinforce the need to provide comprehensive treatment services for opioid use disorder during the co-occurring COVID-19 and opioid crises.

Development of a take-home naloxone program at an urban academic emergency department.

OBJECTIVE: To describe the development of an ED-based take-home naloxone (THN) program in which naloxone kits are dispensed directly to patients during ED discharge. PRACTICE DESCRIPTION: Our THN program was carried out at an urban academic hospital in downtown Chicago, IL. The THN kits consisted of 3 vials of 0.4-mg naloxone and 3 sterile syringes and needles for intramuscular delivery. Any member of the ED team (e.g., physician, pharmacist, or nurse) could recommend naloxone dispensing for a patient; however only the treating ED physician served as the prescriber for record. The ED pharmacist provided bedside education on recognizing opioid overdose and administering naloxone. The naloxone kit was dispensed to the patient at no cost. PRACTICE INNOVATION: This ED pharmacist-led naloxone dispensing model bypasses barriers to naloxone filling and ensures that patients walk out of the emergency department with naloxone in hand. EVALUATION METHODS: We report key metrics from the first 16 months of program implementation, including the number of ED visits for opioid overdose and THN kits dispensed. We further describe the key facilitators and barriers to program development. RESULTS: Over 16 months, our emergency department had 669 unique visits for opioid overdose, and we dispensed 168 THN kits (10.5 per month). We are aware of at least 3 cases in which our THN kits were used to reverse opioid overdose. We faced key informational barriers to program development, such as a lack of knowledge regarding the allowability of ED medication dispensing, as well as financial barriers, such as the need to obtain a supply of naloxone. We also recognized the key facilitators of success, such as early engagement with hospital leadership. CONCLUSION: Implementing a successful THN program is possible in the ED setting, and individual hospital emergency departments seeking to build their own program may benefit from our report.

A Quality Improvement Initiative Featuring Peer-Comparison Prescribing Feedback Reduces Emergency Department Opioid Prescribing.

BACKGROUND: Opioid prescribing in the United States nearly tripled from 1999 to 2015, and opioid overdose deaths doubled in the same time frame. Emergency departments (EDs) may play a pivotal role in the opioid epidemic as a source of first-time opioid exposure; however, many prescribers are generally unaware of their prescribing behaviors relative to their peers. METHODS: All 117 ED prescribers at an urban academic medical center were provided with regular feedback on individual rates of opioid prescribing relative to their de-identified peers. To evaluate the effect of this intervention on the departmental rate of opioid prescribing, a statistical process control (SPC) chart was created to identify special cause variation, and an interrupted time series analysis was conducted to evaluate the immediate effect of the intervention and any change in the postintervention trend due to the intervention. RESULTS: The aggregate opioid prescribing rate in the preintervention period was 8.6% (95% confidence interval [CI]: 8.3%-8.9%), while the aggregate postintervention prescribing rate was 5.8% (95% CI: 5.5%-6.1%). The SPC chart revealed special cause variation in both the pre- and postintervention periods, with an overall downtrend of opioid prescribing rates across the evaluation period and flattening of rates in the final four blocks. Interrupted time series analysis demonstrated a significant immediate downward effect of the intervention and a nonsignificant additional decrease in postintervention trend. CONCLUSION: Implementation of peer-comparison opioid prescribing feedback was associated with a significant immediate reduction in the rate of ED discharge opioid prescribing.

Beta-Adrenergic Blockade Decreases the Neuroimmune Changes in Mice Induced by Cohabitation with an Ehrlich Tumor-Bearing Cage Mate.

OBJECTIVES: Cohabitation with Ehrlich tumor-bearing (ETB) mice induced behavioral, neurochemical, hormonal, and immune effects in the conspecifics as a consequence of stress-induced activation of the sympathetic nervous system (SNS) with catecholamine release. In the current study, the nonspecific ß-AR blocker d,l-propranolol and the specific ß2-AR blocker ICI-118.551 were employed as pharmacological tools to assess the extent to which catecholamines participated in the effects induced by cohabitation with ETB mice. METHODS: Two experiments were performed, 1 with d,l-propranolol treatment and the other with ICI-118.551. One mouse in the experimental group was called the "companion of the sick partner" (CSP) since it was forced to live in the same cage with 2 (experiment 1) or 1 (experiment 2) cage mate that had been i.p. injected with 5 × 106 Ehrlich tumor cells. RESULTS: The d,l-propranolol treatment, but not the ICI-118.551 treatment, attenuated the effects of cohabitation with 2 ETB mice on both open-field behavior and the hypothalamic levels and turnover rate of norepinephrine. The 2 ß-AR blockers were unable to change the serum corticosterone levels and adrenal weights of the CSP mice; however, these drugs abrogated the effects of cohabitation on neutrophil oxidative burst and phagocytosis. Finally, an increase in the 5-HT turnover rate was observed in the olfactory bulb of CSP mice compared to their respective controls, an effect that was not modified by ß-AR blockade. CONCLUSION: These results confirm and strengthen our hypothesis that the SNS is involved in the effects induced by cohabitation with ETB mice and point towards ß2-AR participation in the immune effects analyzed.