Missed Opportunities to Diagnose and Treat Asymptomatic Hypertension in Emergency Departments in the United States, 2016-2019.

BACKGROUND: Fewer than one-half of U.S. adults with hypertension (HTN) have it controlled and one-third are unaware of their condition. The emergency department (ED) represents a setting to improve HTN control by increasing awareness of asymptomatic hypertension (aHTN) according to the 2013 American College of Emergency Physicians asymptomatic elevated blood pressure clinical policy. OBJECTIVE: The aim of the study was to estimate the prevalence and management of aHTN in U.S. EDs. METHODS: We examined the 2016-2019 National Hospital Ambulatory Medical Care Surveys to provide a more valid estimate of aHTN visits in U.S. EDs. aHTN is defined as adult patients with blood pressure ≥ 160/100 mm Hg at triage and discharge without trauma or signs of end organ damage. We then stratified aHTN into a 160-179/100-109 mm Hg subgroup and > 180/110 mm Hg subgroup and examined diagnosis and treatment outcomes. RESULTS: Approximately 5.9% of total visits between 2016 and 2019 met the definition for aHTN and 74% of patients were discharged home, representing an estimated 26.5 million visits. Among those discharged home, emergency physicians diagnosed 13% (95% CI 10.6-15.8%) and treated aHTN in 3.9% (95% CI 2.8-5.5%) of patients in the higher aHTN subgroup. In the lower aHTN subgroup, diagnosis and treatment decreased to 3.1% (95% CI 2.4-4.1%) and 1.2% (95% CI 0.7-2.0%), respectively. CONCLUSIONS: Millions of ED patients found to have aHTN are discharged home without diagnosis or treatment. Although management practices follow clinical policy to delay treatment of aHTN, there are missed opportunities to diagnosis aHTN.

Incidence of Fit Test Failure During N95 Respirator Reuse and Extended Use.

Importance: The COVID-19 pandemic resulted in a widespread acute shortage of N95 respirators, prompting the Centers for Disease Control and Prevention to develop guidelines for extended use and limited reuse of N95s for health care workers (HCWs). While HCWs followed these guidelines to conserve N95s, evidence from clinical settings regarding the safety of reuse and extended use is limited. Objective: To measure the incidence of fit test failure during N95 reuse and compare the incidence between N95 types. Design, Setting, and Participants: This prospective cohort study, conducted from April 2, 2021, to July 15, 2022, at 6 US emergency departments (EDs), included HCWs who practiced N95 reuse for more than half of their clinical shift. Those who were unwilling to wear an N95 for most of their shift, repeatedly failed baseline fit testing, were pregnant, or had facial hair or jewelry that interfered with the N95 face seal were excluded. Exposures: Wearing the same N95 for more than half of each clinical shift and for up to 5 consecutive shifts. Participants chose an N95 model available at their institution; models were categorized into 3 types: dome (3M 1860R, 1860S, and 8210), trifold (3M 1870+ and 9205+), and duckbill (Halyard 46727, 46767, and 46827). Participants underwent 2 rounds of testing using a different mask of the same type for each round. Main Outcomes and Measures: The primary outcome was Occupational Safety and Health Administration-approved qualitative fit test failure. Trained coordinators conducted fit tests after clinical shifts and recorded pass or fail based on participants tasting a bitter solution. Results: A total of 412 HCWs and 824 N95s were fit tested at baseline; 21 N95s (2.5%) were withdrawn. Participants' median age was 34.5 years (IQR, 29.5-41.8 years); 252 (61.2%) were female, and 205 (49.8%) were physicians. The overall cumulative incidence of fit failure after 1 shift was 38.7% (95% CI, 35.4%-42.1%), which differed by N95 type: dome, 25.8% (95% CI, 21.2%-30.6%); duckbill, 28.3% (95% CI, 22.2%-34.7%); and trifold, 61.3% (95% CI, 55.3%-67.3%). The risk of fit failure was significantly higher for trifold than dome N95s (adjusted hazard ratio, 1.75; 95% CI, 1.46-2.10). Conclusions and Relevance: In this cohort study of ED HCWs practicing N95 reuse, fit failure occurred in 38.7% of masks after 1 shift. Trifold N95s had higher incidence of fit failure compared with dome N95s. These results may inform pandemic preparedness, specifically policies related to N95 selection and reuse practices.

Effect of an ultrasound-first clinical decision tool in emergency department patients with suspected nephrolithiasis: A randomized trial.

INTRODUCTION: Previously, we found that the use of ultrasonography for patients with suspected nephrolithiasis resulted in similar outcomes and less radiation exposure vs. CT scan. In this study, we evaluated the implementation of an ultrasound-first clinical decision support (CDS) tool in patients with suspected nephrolithiasis. METHODS: This randomized trial was conducted at an academic emergency department (ED). We implemented the ultrasound-first CDS tool, deployed when an ED provider placed a CT order for suspected nephrolithiasis. Providers were randomized to receiving the CDS tool vs. usual care. The primary outcome was receipt of CT during the index ED visit. Secondary outcomes included radiation dose and ED revisit. RESULTS: 64 ED Providers and 254 patients with suspected nephrolithiasis were enrolled from January 2019 through Dec 2020. The US-First CDS tool was deployed for 128 patients and was not deployed for 126 patients. 86.7% of patients in the CDS arm received a CT vs. 94.4% in the usual care arm, resulting in an absolute risk difference of -7.7% (-14.8 to -0.6%). Mean radiation dose in the CDS arm was 6.8 mSv (95% CI 5.7-7.9 mSv) vs. 6.1 mSv (95% CI 5.1-7.1 mSv) in the usual care arm. The CDS arm did not result in increased ED revisits, CT scans, or hospitalizations at 7 or 30 days. CONCLUSIONS AND RELEVANCE: Implementation of the US-first CDS tool resulted in lower CT use for ED patients with suspected nephrolithiasis. The use of this decision support may improve the evaluation of a common problem in the ED. TRIAL REGISTRATION: ClinicalTrials.gov#NCT03461536.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals.

PURPOSE: Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals. METHOD: In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list. RESULTS: This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury. CONCLUSIONS: Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Trends in Use of Diagnostic Imaging for Abdominal Pain in U.S. Emergency Departments.

OBJECTIVE. CT has excellent accuracy for appendicitis but is associated with risks. Research and educational campaigns have been conducted to implement an ultrasound-first strategy for children but not for adults. The purpose of this study was to measure the use of CT and ultrasound in emergency department (ED) visits for abdominal pain and appendicitis to examine the impact of these efforts. MATERIALS AND METHODS. We analyzed data from the National Hospital Ambulatory Medical Care Survey (1997-2016). Use of CT and ultrasound was measured over time in visits for abdominal pain and visits in which appendicitis was diagnosed. Predictors of CT use were identified by means of regression analysis. RESULTS. For children, CT use increased from 1.2% (95% CI, 0.6-2.5%) in 1997, peaked in 2010 at 16.6% (95% CI, 13.8-19.6%), and decreased slightly in 2016. In adults, CT use increased steadily from 3.9% in 1997 (95% CI, 3.1-4.8%) to 37.8% (95% CI, 35.5-41.0%) in 2016. CT use increased for both pediatric and adult ED visits with a diagnosis of appendicitis, from 5.2% (95% CI, 0.7-29.5%) to 71.0% (95% CI, 43.1-88.8%) for children and 7.2% (95% CI, 2.7-17.6%) to 83.3% (95% CI, 64.1-93.3%) for adults. Children with abdominal pain and a diagnosis of appendicitis evaluated in a pediatric ED were at decreased odds (pain odds ratio, 0.6 [95% CI, 0.3-0.9]; appendicitis odds ratio, 0.2 [95% CI, 0.0-0.7]) of receiving CT than were those evaluated in general EDs. CONCLUSION. CT use has decreased in the evaluation of abdominal pain in children, perhaps because of research findings and efforts to implement an ultrasound-first strategy for suspected appendicitis. In contrast, CT use has continued to increase among adults with abdominal pain in EDs.

Emergency department preparation for COVID-19: accelerated care units.

By 11 February 2020 when the WHO named the novel coronavirus (SARS-CoV-2) and the disease it causes (COVID-19), it was evident that the virus was spreading rapidly outside of China. Although San Francisco did not confirm its first locally transmitted cases until the first week of March, our ED and health system began preparing for a potential COVID-19 surge in late February 2020.In this manuscript, we detail how the above responses were instrumental in the rapid deployment of two military-grade negative-pressure medical tents, named accelerated care units (ACU). We describe engagement of our workforce, logistics of creating new care areas, ensuring safety through personal protective equipment access and conservation, and the adaptive leadership challenges that this process posed.We know of no other comprehensive examples of how EDs have prepared for COVID-19 in the peer-reviewed literature. Many other EDs both in and outside of California have requested access to the details of how we operationalised our ACUs to facilitate their own planning. This demonstrates the urgent need to disseminate this information to our colleagues. Below we describe the process of developing and launching our ACUs as a potential model for other EDs around the country.

Potential Effect of the Protecting Access to Medicare Act on Use of Advanced Diagnostic Imaging in the Emergency Department: An Analysis of the National Hospital Ambulatory Care Survey.

Background Clinical decision support is increasingly used to enhance clinicians' exposure to established evidence and patient information during an episode of patient care. Pending legislation specifies clinical decision support before performing advanced imaging at emergency department (ED) visits. Purpose To estimate the volume of advanced imaging tests (CT and MRI) that would require use of clinical decision support to achieve Protecting Access to Medicare Act (PAMA) compliance in the ED. Materials and Methods A retrospective, cross-sectional analysis of ED visits was conducted by using data from the 2012-2015 National Hospital Ambulatory Care Survey. PAMA-related visits were identified by selecting the patient reasons for visit (RFVs) related to the eight clinical conditions. Results Among the adult ED visits, 26.7% (20 506 of 77 299, representing 113 000 000 visits across 4 years, or 28 000 000 visits annually) patients presented with a RFV consistent with a PAMA priority clinical area (PCA). Among visits in which a patient described an RFV code consistent with a PAMA PCA, up to 22.9% (4681 of 20 506; 95% confidence interval: 21.8%, 24.1%) patients underwent advanced imaging, translating to approximately 6 000 000 visits annually. Conclusion Protecting Access to Medicare Act legislation targets eight priority clinical areas, estimated to be prevalent among one in four adult emergency department visits. CT and/or MRI studies are performed during up to 23% of these visits. Depending on the particular clinical decision support systems selected within a health system, and how they are implemented, the potential volume of studies in which clinicians must interact with clinical decision support system may either exceed or fall short of these estimates. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Forman in this issue.

Computed Tomography Use Plateaus Among Children With Emergency Visits for Abdominal Pain.

OBJECTIVES: Abdominal pain is a common pediatric complaint to emergency departments (EDs), and clinicians often rely on imaging for diagnosis. Studies have demonstrated an increase in computed tomography (CT) in this population. Following emphasis on radiation reduction by researchers and organizations, this study evaluates recent national trends in CT use among pediatric patients presenting to EDs with abdominal pain. METHODS: This is a cross-sectional analysis of ED patients 18 years or younger with chief complaint of abdominal pain in the National Hospital Ambulatory Medical Care Survey from 2008 to 2011. Outcomes include annual proportions of visits with x-ray, ultrasound, or CT, as well as diagnosis of appendicitis and hospital admission. RESULTS: Of 32,304 ED visits, 2120 (6.6%) were for abdominal pain. Proportions of visits using CT, ultrasound, and plain x-ray were 16.0%, 10.5%, and 23.4%, respectively. For all outcome measures, including imaging, hospital admission, and diagnosis of appendicitis, there was no change from 2008 to 2011. Considering previous data, there was a significant rise in ultrasound use from 5.4% (95% confidence interval, 2.4%-8.4%) in 1998 to 12.1% (95% confidence interval, 9.4%-13.7%) in 2011. Multivariate analysis of CT use found the strongest predictor to be increasing age. Females, black children, and those with Medicaid insurance had lower odds of having a CT. CONCLUSIONS: In contrast to the earlier dramatic increase in CT use for pediatric patients with abdominal pain, CT remained constant between 2008 and 2011. There was no associated change in the rate of diagnosis of appendicitis or hospitalization; however, ultrasound is increasing.

Long-term Mortality in Pediatric Firearm Assault Survivors: A Multicenter, Retrospective, Comparative Cohort Study.

OBJECTIVES: The objective was to determine whether children surviving to hospital discharge after firearm assault (FA) and nonfirearm assault (NFA) are at increased risk of mortality relative to survivors of unintentional trauma (UT). Secondarily, the objective was to elucidate the factors associated with long-term mortality after pediatric trauma. METHODS: This was a multicenter, retrospective cohort study of pediatric patients aged 0 to 16 years who presented to the three trauma centers in San Francisco and Alameda counties, California, between January 2000 and December 2009 after 1) FA, 2) NFA, and 3) UT. The Social Security Death Master File and the California Department of Public Health Vital Statistics (2000-2014) were queried through December 31, 2014, to identify those who died after surviving their initial hospitalization and to delineate cause of death. Multivariate Cox proportional hazards regression was performed to determine associations between exposure to assault and long-term mortality. RESULTS: We analyzed 413 FA, 405 NFA, and 7,062 UT patients who survived their index hospital visit. A total of 75 deaths occurred, including 3.9, 3.2, and 0.7% of each cohort, respectively. Two-thirds of all long-term deaths were due to homicide. After multivariate adjustment, adolescent age, male sex, black race/ethnicity, and public insurance were independent risk factors for long-term mortality. FA (adjusted hazard ratio [AHR] = 1.8, 95% confidence interval [CI] = 0.82-4.0) and NFA (AHR = 1.9, 95% CI = 0.93-3.9) did not convey a statistically significant difference in risk of long-term mortality compared to UT. Being assaulted by any means (with or without a firearm), however, was an independent risk factor for long-term mortality in the full study population (AHR = 1.9, 95% CI = 1.01-3.4) and among adolescents (AHR = 1.9, 95% CI = 1.01-3.6). CONCLUSION: Children and adolescents who survive assault, including by firearm, have increased long-term mortality compared to those who survive unintentional, nonviolent trauma.

Cardiovascular and Cerebrovascular Emergency Department Visits Associated With Wildfire Smoke Exposure in California in 2015.

BACKGROUND: Wildfire smoke is known to exacerbate respiratory conditions; however, evidence for cardiovascular and cerebrovascular events has been inconsistent, despite biological plausibility. METHODS AND RESULTS: A population-based epidemiologic analysis was conducted for daily cardiovascular and cerebrovascular emergency department (ED) visits and wildfire smoke exposure in 2015 among adults in 8 California air basins. A quasi-Poisson regression model was used for zip code-level counts of ED visits, adjusting for heat index, day of week, seasonality, and population. Satellite-imaged smoke plumes were classified as light, medium, or dense based on model-estimated concentrations of fine particulate matter. Relative risk was determined for smoky days for lag days 0 to 4. Rates of ED visits by age- and sex-stratified groups were also examined. Rates of all-cause cardiovascular ED visits were elevated across all lags, with the greatest increase on dense smoke days and among those aged ≥65 years at lag 0 (relative risk 1.15, 95% confidence interval [1.09, 1.22]). All-cause cerebrovascular visits were associated with smoke, especially among those 65 years and older, (1.22 [1.00, 1.49], dense smoke, lag 1). Respiratory conditions were also increased, as anticipated (1.18 [1.08, 1.28], adults >65 years, dense smoke, lag 1). No association was found for the control condition, acute appendicitis. Elevated risks for individual diagnoses included myocardial infarction, ischemic heart disease, heart failure, dysrhythmia, pulmonary embolism, ischemic stroke, and transient ischemic attack. CONCLUSIONS: Analysis of an extensive wildfire season found smoke exposure to be associated with cardiovascular and cerebrovascular ED visits for all adults, particularly for those over aged 65 years.

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics.

BACKGROUND/OBJECTIVE: Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia. METHODS: We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated. RESULTS: We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90). CONCLUSIONS: For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.

The Highland Health Advocates: a preliminary evaluation of a novel programme addressing the social needs of emergency department patients.

OBJECTIVES: Patients commonly come to the emergency department (ED) with social needs. To address this, we created the Highland Health Advocates (HHA), an ED-based help desk and medical-legal partnership using undergraduate volunteers to help patients navigate public resources and provide onsite legal and social work referrals. We were able to provide these services in English and Spanish. We aimed to determine the social needs of the patients who presented to our ED and the potential impact of the programme in resolving those needs and connecting them to a 'medical home' (defined as a consistent, primary source of medical care such as a primary care doctor or clinic). METHODS: ED patients at a US safety net hospital were enrolled in a 1:2 ratio in a quasi-experiment comparing those who received intervention from the HHA during a limited access rollout with controls who received usual care on days with no help desk. We collected a baseline social needs evaluation, with follow-up assessments at 1 and 6 months. Primary outcomes were linkages for the primary identified need and to a medical home within 1 month. Other outcomes at 6 months included whether a patient (1) felt helped; 2) had a decreased number of ED visits; (3) had the primary identified need met; (4) had a primary doctor; and (5) had a change in self-reported health status. RESULTS: We enrolled 459 subjects (intervention=154, control=305). Housing (41%), employment (23%) and inability to pay bills (22%) were participants' top identified needs. At baseline, 32% reported the ED as their medical home, with the intervention cohort having higher ED utilisation (>1 ED visit in the prior month: 49% vs 24%). At 1 month, 185 (40%) subjects were reached for follow-up, with more HHA subjects linked to a resource (59% vs 37%) and a medical home (92% vs 76%). At 6 months, 75% of subjects felt HHA was helpful and more subjects in the HHA group had a doctor (93% v 69%). No difference was found in ED utilisation, primary need resolution or self-reported health status. CONCLUSIONS: Health-related social needs are common in this US safety net ED. Our help desk is one possible model for addressing social needs.

Derivation of decision rules to predict clinically important outcomes in acute flank pain patients.

OBJECTIVE: Routine CT for patients with acute flank pain has not been shown to improve patient outcomes, and it may unnecessarily expose patients to radiation and increased costs. As preliminary steps toward the development of a guideline for selective CT, we sought to determine the prevalence of clinically important outcomes in patients with acute flank pain and derive preliminary decision rules. METHODS: We analyzed data from a randomized trial of CT vs. ultrasonography for patients with acute flank pain from 15 EDs between October 2011 and February 2013. Clinically important outcomes were defined as inpatient admission for ureteral stones and alternative diagnoses. Clinically important stones were defined as stones requiring urologic intervention. We sought to derive highly sensitive decision rules for both outcomes. RESULTS: Of 2759 participants, 236 (8.6%) had a clinically important outcome and 143 (5.2%) had a clinically important stone. A CDR including anemia (hemoglobin <13.2g/dl), WBC count >11000/µl, age>42years, and the absence of CVAT had a sensitivity of 97.9% (95% CI 94.8-99.2%) and specificity of 18.7% (95% 17.2-20.2%) for clinically important outcome. A CDR including hydronephrosis, prior history of stone, and WBC count <8300/µl had a sensitivity of 98.6% (95% CI 94.5-99.7%) and specificity of 26.0% (95% 24.2-27.7%) for clinically important stone. CONCLUSIONS: We determined the prevalence of clinically important outcomes in patients with acute flank pain, and derived preliminary high sensitivity CDRs that predict them. Validation of CDRs with similar test characteristics would require prospective enrollment of 2100 patients.