Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services

ObjectivesRoutine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation.MethodsCross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017–July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care.ResultsThere were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%–8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%–23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services.ConclusionsPatients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.     

A four-year observation of HIV and sexually transmitted infections among men who have sex with men before and during pre-exposure prophylaxis in Tokyo

BackgroundPre-exposure prophylaxis (PrEP) with tenofovir/emtricitabine (TDF/FTC) has been recommended worldwide. We evaluated the safety and efficacy of daily PrEP with TDF/FTC in Tokyo.MethodsThis single-center, single-arm study was performed with 124 men who have sex with men (MSM) between January 2017 and March 2021. MSM who entered into an MSM cohort from January 2017 through March 2018 and had a pre-PrEP observational period of 1 year were eligible and recruited to the study between April 2018 and March 2019 and followed for 2 years. The primary outcome was the incidence of HIV infection (per 100 person-years). Secondary outcomes were the incidence of sexually transmitted infections and adverse events, and the rate of retention and adherence to PrEP.ResultsThere were 309 MSM registered in the cohort (mean age, 36.6 years); 124 fulfilled the criteria and were included in the study. The remaining patients were continuously followed. There was a significant decrease in incidental HIV infection among PrEP users (0 infections, 235.5 person-years) compared to non-PrEP users (11 infections [3.4%/year], 318.9 person-years; p = 0.01). The average adherence rate was consistently greater than 95%, and the retention rate at two years was approximately 80%.ConclusionsThe present study showed a high prophylactic effect against HIV infection, retention, and adherence to PrEP. PrEP is feasible and highly recommended in Japan.Trial registrationUMIN Clinical Trials Registry (UMIN000031040, www.umin.ac.jp), Japan Registry of Clinical Trials (jRCTs031180134).     

Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments

BackgroundSeizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates.ObjectiveTo compare rates of head CT for pediatric seizure between general and pediatric EDs.MethodsThis was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model.ResultsMore than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3–16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0–31.9]), without fever (12.2% [95% CI 3.1–21.4]), and without trauma (10.6% [95% CI 4.4–16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0–3.2), 4.9 (95% CI 2.6–9.2), and 2.0 (95% CI 1.2–3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure.ConclusionsChildren with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.     

Post-exposure prophylaxis for human immunodeficiency virus after sexual assault in a Midwestern U.S. emergency department

BackgroundEmergency departments (EDs) play an essential role in the timely initiation of HIV post-exposure prophylaxis (PEP) for sexual assault victims.MethodsRetrospective analysis of sexual assault victims evaluated and offered HIV PEP in an urban academic ED between January 1, 2005 and January 1, 2018. Data on demographics, comorbidities, nature of sexual assault, initial ED care, subsequent healthcare utilization within 28 days of initial ED visit, and evidence of seroconversion within 6 months of the initial ED visit were obtained. Predictors of subsequent ED visit and follow-up in the infectious diseases clinic were evaluated using logistic regression analysis.ResultsFour hundred twenty-three ED visits met criteria for inclusion in this study. Median age at ED presentation was 25 years (IQR 21–34 years), with the majority of victims being female (95.5%), Black (63.4%), unemployed (66.3%) and uninsured (53.9%); psychiatric comorbidities (38.8%) and substance abuse (23.6%) were common. About 87% of the patients accepted HIV PEP (368 of 423 ED visits). Age (OR 0.97, 95% CI 0.94–0.99, p = 0.025) and sexual assault involving >1 assailant (OR 0.48, 95% CI 0.26–0.88, p = 0.018) were associated with lower likelihood of HIV PEP acceptance. Ten patients (2.7%) followed up with the infectious disease clinic within 28 days of starting HIV PEP; 70 patients (19%) returned to the ED for care during the same time period. Psychiatric comorbidity (OR 2.48, 95% CI 1.43–4.30, p = 0.001) and anal penetration (OR 2.02, 95% CI 1.10–3.70, p = 0.024) were associated with greater likelihood of repeat ED visit; female gender (OR 0.30, 95% CI 0.11–0.85, p = 0.023) was associated with lower likelihood of repeat visit. Completion of HIV PEP was documented for 14 (3.3%) individuals.ConclusionsWhile ED patient acceptance of HIV PEP after sexual assault was high, infectious disease clinic follow-up and documented completion of PEP remained low. Innovative care models bridging EDs to outpatient clinics and community support services are needed to optimize transitions of care for sexual assault victims, including those receiving HIV PEP.     

Interfacility transports by emergency medical services in the United States: Estimates from the National Hospital Ambulatory Medical Care Survey

ObjectiveTo describe characteristics of encounters in U.S. emergency departments (EDs) brought by interfacility transport by emergency medical services (EMS) from other EDs or urgent care settings.MethodsWe performed a cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a multistage probability survey of nonfederal of visits to U.S. EDS. We evaluated patients who were brought to the ED as an interfacility transport by EMS from another ED or urgent care setting between 2014 and 2017. We report demographics, clinical characteristics and treatment factors of ED encounters brought interfacility transport and assessed factors associated with discharge from the receiving ED.ResultsOf 562.9 million ED encounters during the assessed period, 4.5 million were brought by interfacility transport by EMS (1.1 million per year). This represented 0.8% (95% CI 0.6–1.0%) of all ED encounters and 5.3% (95% CI 4.4–6.3%) of ED encounters transported by EMS. Most encounters brought by interfacility transport were adults (85%) who were publicly insured (62%). 39% had at least one abnormal vital sign. Most encounters received diagnostic testing (84%) and were seen within 30 min of presentation (61%). 54% were admitted, and 36% were discharged from the ED. Encounters without chronic complex conditions and with normal triage vital signs were associated with ED discharge (p < 0.01).DiscussionInterfacility transports between EDs transported by EMS account for <1% of ED encounters in the U.S. Nearly 40% of such encounters are ultimately discharged. Further research is needed to identify a low-risk cohort among patients in need of secondary transport.     

Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

PurposeTo characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list.MethodsThis was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017–2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury.Results305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%–42.6%) for XR, 19.1% (IQR 11.4%–24.9%) for CT, and 0.09% (IQR 0%–0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%–61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%–81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: −12.7%, −4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: −7.3%, −1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: −5.9%, −0;5%), CT (20.1% vs 17.7%; 95% CI: −5.1%, −0.4%) or MRI (0.8% vs 0.7%, 95% CI: −0.4%, −0.3%).ConclusionsEarly data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.     

eccSOFA: SOFA illness severity score adapted to predict in-hospital mortality in emergency critical care patients

BackgroundBoarding of ICU patients in the ED is increasing. Illness severity scores may help emergency physicians stratify risk to guide earlier transfer to the ICU and assess pre-ICU interventions by adjusting for baseline mortality risk. Most existing illness severity scores are based on data that is not available at the time of the hospital admission decision or cannot be extracted from the electronic health record (EHR). We adapted the SOFA score to create a new illness severity score (eccSOFA) that can be calculated at the time of ICU admission order entry in the ED using EHR data. We evaluated this score in a cohort of emergency critical care (ECC) patients at a single academic center over a period of 3 years.MethodsThis was a retrospective cohort study using EHR data to assess predictive accuracy of eccSOFA for estimating in-hospital mortality risk. The patient population included all adult patients who had a critical care admission order entered while in the ED of an academic medical center between 10/24/2013 and 9/30/2016. eccSOFA's discriminatory ability for in-hospital mortality was assessed using ROC curves.ResultsOf the 3912 patients whose in-hospital mortality risk was estimated, 2260 (57.8%) were in the low-risk group (scores 0–3), 1203 (30.8%) in the intermediate-risk group (scores 4–7), and 449 (11.5%) in the high-risk group (scores 8+). In-hospital mortality for the low-, intermediate, and high-risk groups was 4.2% (95%CI: 3.4–5.1), 15.5% (95% CI 13.5–17.6), and 37.9% (95% CI 33.4–42.3) respectively. The AUROC was 0.78 (95%CI: 0.75–0.80) for the integer score and 0.75 (95% CI: 0.72–0.77) for the categorical eccSOFA.ConclusionsAs a predictor of in-hospital mortality, eccSOFA can be calculated based on variables that are commonly available at the time of critical care admission order entry in the ED and has discriminatory ability that is comparable to other commonly used illness severity scores. Future studies should assess the calibration of our absolute risk predictions.     

Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties

BackgroundRefocused national HIV testing initiatives include a geographic focus.ObjectiveUsing a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example.MethodsRetrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties.ResultsOf the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01).ConclusionsEDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.     

Interleukin-6 improves infection identification when added to physician judgment during evaluation of potentially septic patients

BackgroundIdentifying infection is critical in early sepsis screening. This study assessed whether biomarkers of endothelial activation and/or inflammation could improve identification of infection among Emergency Department (ED) patients with organ dysfunction.MethodsWe performed a prospective, observational study at two urban, academic EDs, between June 2016 and December 2017. We included admitted adults with 1) two systemic inflammatory response syndrome criteria and organ dysfunction, 2) systolic blood pressure < 90 mmHg, or 3) lactate ≥4.0 mmol/L. We excluded patients with trauma, transferred for intracranial hemorrhage, or without available blood samples. Treating ED physicians reported presence of infection (yes/no) at inpatient admission. Assays for angiopoietin-1, angiopoietin-2, soluble tumor necrosis factor receptor-1, interleukin-6, and interleukin-8 were performed using ED blood samples. The primary outcome was infection, adjudicated by paired physician review. Using logistic regression, we compared the performance of physician judgment, biomarkers, and physician judgment-biomarkers combination to predict infection. Area under the curve (AUC) and AUC 95% confidence intervals were estimated by bootstrap procedure.ResultsOf 421 patients enrolled, 306 patients met final study criteria. Of these, 154(50.3%) patients had infectious etiologies. Physicians correctly discriminated infectious from non-infectious etiologies in 239 (78.1%). Physician judgment performed moderately when discriminating infection (AUC 0.78, 95% CI: 0.74–0.82) and outperformed the best biomarker model, interleukin-6 alone, (AUC 0.71, 0.66–0.76). Physician judgment improved when including interleukin-6 (AUC 0.84, 0.79–0.87), with modest AUC improvement: 0.06 (0.03–0.08).ConclusionsIn ED patients with organ dysfunction, plasma interleukin-6 may improve infection discrimination when added to physician judgment.     

Physician assistant utilization in U.S. emergency departments; 2010 to 2017

BackgroundPhysician Assistants (PAs) are widely used in United States (US) Emergency Departments (EDs). We sought to characterize ED PA utilization and practice characteristics in US EDs 2010–2017.MethodsA retrospective, secondary analysis of the 2010 to 2017 Center for Disease Control's National Hospital Ambulatory Medical Care Survey (NHAMCS) was performed. National estimates of ED visits involving PAs alone (PA), PAs with physician involvement (PA+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics.ResultsBetween 2010 and 2017, an estimated 1 billion US ED visits occurred. 5.0% (95% confidence interval [CI] ±2.7%) of visits were seen by a PA, and 8.2% (±2.7%) by a PA+; 76.3% (±7.2%) by PHYS. No linear trends by year were identified in PA or PA+ visits. PA acuity was highest for semi-urgent/nonurgent (56.4%, ±10.7%). PA see the minority of ambulance arrival [5.8% (±1.3)] and admit less patients [1.7% (±0.7%)]. Less laboratory [53.3% (±10.2%) vs. 67.0% (±6.2%)] and radiographic [38.8% (±6.6%) vs. 51.6% (±4.6%) studies were performed during PA vs. PHYS visits. PA visits were most common for patients 25–44 years old (yo) (32.9%, ±6.2%) and 15–24 yo (19.2%, ±3.7%). Most PA visits result in a length of stay (LOS) between 1 and 1.9 h (32.9%, ±6.7%) compared to most PHYS visits resulting in a LOS >3 h (40.3%, ±3%).ConclusionsFrom 2010 to 2017, no linear trends in US ED PA and PA+ utilization were identified. PHYS continue to see the majority of ED patients.     

Trends in Midlevel Provider Utilization in Emergency Departments from 1997 to 2006

Objectives: The objective was to quantify the expansion of midlevel provider (MLP) practice in U.S. emergency departments (EDs) over the past decade. Specifically, we sought to quantify the absolute number of patients seen by MLPs, the annual growth rate of patients seen by MLPs, and the expansion in the proportion of EDs using MLPs. Methods: Data were analyzed from the ED portion of the 10 most recent years (1997 to 2006) National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of ED visits compiled by the Centers for Disease Control and Prevention (CDC). The main outcomes of interest were the proportion and absolute numbers of ED patients seen by MLPs during the 10‐year study period. National estimates derived from sample weights are reported. In addition, a multivariate logistic regression model was created with “seen by midlevel provider” as the dependent variable to determine factors associated with being seen by a MLP. Results: Between 1997 and 2006, 8.23% (95% confidence interval [CI] = 7.31% to 9.15%) of ED patients were seen by a MLP. The proportion of ED patients seen by MLPs increased from 5.5% (95% CI = 3.8% to 7.1%) in 1997 to 12.7% (95% CI = 10.5% to 14.9%) in 2006 (13% annual growth). This corresponds to an increase in the number of ED patients seen by MLPs from 5.2 million in 1997 to 15.2 million in 2006. The proportion of hospitals using MLPs in the ED increased from 28.3% (95% CI = 22.4% to 34.1%) in 1997 to 77.2% (95% CI = 71.2% to 83.3%) in 2006 (17% annual growth). Slightly over half of MLP cases (54.9%; 95% CI = 49.1% to 60.7%) were also seen by staff physicians. On multivariate regression, younger patient age, non–southern geographic region, and triage acuity were associated with increased MLP use. Conclusions: The number of ED patients seen by MLPs has increased sharply, from 5.2 million in 1997 (5.5% of all ED cases) to 15.2 million in 2006 (12.7% of all ED cases). Similarly, the proportion of EDs reporting use of MLPs has increased from 28.3% in 1997 to 77.2% in 2006.     

Factors associated with first-pass success of emergency endotracheal intubation

Study objectiveEndotracheal intubation is frequently performed in emergency departments (EDs). First-pass success is important because repeated attempts are associated with poor outcomes. We sought to identify factors associated with first-pass success in emergency endotracheal intubation.MethodsWe analyzed emergency orotracheal intubations on adult patients in an ED located in South Korea from Jan. 2013 to Dec. 2016. Various operator-, procedure- and patient-related factors were screened with univariable logistic regression. Using variables with P-values less than 0.2, a multiple logistic regression model was constructed to identify independent predictors.ResultsThere were 1154 eligible cases. First-pass success was achieved in 974 (84.4%) cases. Among operator-related factors, clinical experience (OR: 2.93, 5.26, 3.80 and 5.71; 95% CI: 1.62–5.26, 2.80–9.84, 1.81–8.13 and 2.07–18.67 for PGY 3, 4 and 5 residents and EM specialists, respectively, relative to PGY 2 residents) and physician based outside the ED (OR: 0.10; 95% CI: 0.04–0.25) were independently associated with first-pass success. There was no statistically or clinically significant difference for first-pass success rate as determined by operator's gender (83.6% for female vs. 84.8% for male; 95% CI for difference: −3.1% to 5.8%). Among patient-related factors, restricted mouth opening (OR: 0.47; 95% CI: 0.31–0.72), restricted neck extension (OR: 0.57; 95% CI: 0.39–0.85) and swollen tongue (OR: 0.46; 95% CI: 0.28–0.77) were independent predictors of first-pass success.ConclusionsOperator characteristics, including clinical experience and working department, and patient characteristics, including restricted mouth opening, restricted neck extension and swollen tongue, were independent predictors of first-pass success in emergency endotracheal intubation.     

Effect of previous emergency psychiatric consultation on suicide re-attempts – A multi-center observational study

BackgroundThe emergency department (ED) is one of the first gateways when suicide attempt patients seek health care services. The purpose of this study was to analyze the hypothesis that people who received emergency psychiatric services in previous suicide attempts will have a lower mortality rate in current ED visits owing to subsequent suicide attempts.MethodThis retrospective study included patients who visited six EDs, and participated in the injury surveillance and in-depth suicide surveillance for 10 years, from January 2008 to December 2017. The study subjects were adult patients 18 years or older who visited EDs due to suicide attempts. The main explanatory variable is whether psychiatric treatment was provided in previous suicide attempts. The main outcome variable was suicide related mortality.ResultsThe study included 2144 suicide attempt patients with a previous history of suicide attempts. Among these, 1335 patients (62.2%) had received psychiatric treatment in previous suicide attempts. Mortality was significantly different between the psychiatric consultation group (n = 33, 2.5%) and non-consultation group (n = 47, 5.8%) (P < 0.01). In multivariate logistic regression analysis, previous psychiatric consultation showed a significant association with low mortality (adjusted OR 0.41; 95% CI [0.23–0.72]) and selecting non-fatal suicide methods (adjusted OR 0.47; 95% CI [0.36–0.61]).ConclusionPatients who received psychiatric consultation in previous suicide attempts had a lower suicide-related mortality in current ED visits as compared to patients who did not, and this may have been related to choosing non-fatal suicide methods.     

Compliance with Recommended Cancer Screening among Emergency Department Patients: A Multicenter Survey

Objectives: The objectives were to measure compliance with, and possible sociodemographic disparities for, cancer screening among emergency department (ED) patients. Methods: This was a cross‐sectional survey in three academic EDs in Boston. The authors enrolled consecutive adult patients during two 24‐hour periods at each site. Self‐reported compliance with standard recommendations for cervical, breast, testicular, and prostate cancer screening were measured. The chi‐square test was used test to evaluate associations between demographic variables and cancer screening compliance. Results: The authors enrolled 387 patients (81% of those eligible). The participants had a mean (±standard deviation) age of 44 (±18) years and were 52% female, 16% Hispanic, and 65% white. Sixty‐seven percent (95% confidence interval [CI] = 60% to 73%) of all women reported Pap smear examinations in the past 3 years, 92% (95% CI = 85% to 96%) of women aged ≥40 years reported clinical breast examinations, and 88% (95% CI = 81% to 94%) of women aged ≥40 years reported mammography. Fifty‐one percent (95% CI = 40% to 61%) of men aged 18–39 years reported testicular self‐examinations, and among men aged ≥40 years, 79% (95% CI = 69% to 87%) reported digital rectal examinations (DREs) and 51% (95% CI = 40% to 61%) reported prostate‐specific antigen (PSA) testing. Racial and ethnic minorities reported slightly lower rates of clinical breast examinations and testicular self‐examinations. Conclusions: Most women and a majority of men in our ED‐based study were compliant with recommended measures of cervical, breast, testicular, and prostate cancer screening. No large sociodemographic disparities in our patient population were identified. Based on these data, and the many other pressing public health needs of our ED population, the authors would be reluctant to promote ED‐based cancer screening initiatives at this time.     

Smoking Habits of Emergency Department Patients: An Opportunity for Disease Prevention

Objective: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.
Methods: A questionnaire was administered prospectively to all non-critical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.
Results: The study patients were mostly young (mean age = 35 ± 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36–0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46–0.64) of these patients were current smokers.
Conclusions: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.     

Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City

BackgroundPreviously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach.ObjectivesWe examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED.MethodsRetrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion.ResultsThere were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%.ConclusionsNontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.     

Availability of Rapid Human Immunodeficiency Virus Testing in Academic Emergency Departments

Objectives:  The Centers for Disease Control and Prevention (CDC) recommends routine human immunodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. The study objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify factors that influence an ED's adoption of testing, and to describe current HIV testing practices.
Methods:  Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs ( n  = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent ( n  = 102) responded. Most e-mail recipients ( n  = 121) were Emergency Medicine Network (EMNet) investigators; remaining contacts were obtained from residency-related Web sites.
Results:  Most academic EDs ( n  = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIV testing. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32 EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than 10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offer HIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation could link an HIV-positive patient to subspecialty care. The facility characteristic most important to availability of rapid HIV testing was the presence of on-site HIV counselors.
Conclusions:  Most academic EDs now offer rapid HIV testing (57%), but few use it in situations other than occupational exposure. Less than half of academic EDs expect to implement CDC guidelines regarding routine screening within the next few years. The authors identified facility characteristics (e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.     

Emergency department visits for electric scooter-related injuries after introduction of an urban rental program

BackgroundProviders in Salt Lake City emergency departments (EDs) anecdotally noted a significant number of electronic scooter (e-scooter)-related injuries since the launch of e-scooter rentals in the downtown area in June 2018. The aim of this study was to quantify and characterize these injuries.MethodsWe reviewed the electronic medical records of the University of Utah ED and the Salt Lake Regional Medical Center ED. Using a broad keyword search for “scooter,” we examined all notes for ED visits between June 15–November 15, 2017, and June 15–November 15, 2018, and identified e-scooter related injuries. The 2017 data pre-dated the launch of the e-scooter share programs in Salt Lake City and served as a control period.ResultsWe noted 8 scooter-related injuries in 2017 and 50 in 2018. Injury types from the 2018 period included: major head injury (8%); major musculoskeletal injury (36%); minor head injury (12%); minor musculoskeletal injury (34%); and superficial soft tissue injury (40%). 24% of patients presented via ambulance and 6% presented as a trauma activation. 16% of patients required hospital admission and 14% had an injury requiring operative repair. 16% reported alcohol intoxication and none of the patients reported wearing a helmet at the time of the injury.ConclusionSince the launch of e-scooter share programs in Salt Lake City, we have seen a substantial increase in e-scooter related trauma in our EDs. Of particular note is the number of patients with major head injuries and major musculoskeletal injuries.