Mental Health–related Emergency Department Visits Associated With Cannabis in Colorado

Background

Cannabis legalization in Colorado resulted in increased cannabis‐associated health care utilization. Our objective was to examine cooccurrence of cannabis and mental health diagnostic coding in Colorado emergency department (ED) discharges and replicate the study in a subpopulation of ED visits where cannabis involvement and psychiatric diagnosis were confirmed through medical review.

Methods

We collected statewide ED International Classification of Diseases, 9th Revision, Clinical Modification diagnoses from the Colorado Hospital Association and a subpopulation of ED visits from a large, academic hospital from 2012 to 2014. Diagnosis codes identified visits associated with mental health and cannabis. Codes for mental health conditions and cannabis were confirmed by manual records review in the academic hospital subpopulation. Prevalence ratios (PRs) of mental health ED discharges were calculated to compare cannabis‐associated visits to those without cannabis. Rates of mental health and cannabis‐associated ED discharges were examined over time.

Results

Statewide data demonstrated a fivefold higher prevalence of mental health diagnoses in cannabis‐associated ED visits (PR = 5.35, 95% confidence interval [CI], 5.27–5.43) compared to visits without cannabis. The hospital subpopulation supported this finding with a fourfold higher prevalence of psychiatric complaints in cannabis attributable ED visits (PR = 4.87, 95% CI = 4.36–5.44) compared to visits not attributable to cannabis. Statewide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p < 0.0001).

Conclusions

In Colorado, the prevalence of mental health conditions in ED visits with cannabis‐associated diagnostic codes is higher than in those without cannabis. There is a need for further research determining if these findings are truly attributed to cannabis or merely coincident with concurrent increased use and availability.

     

Understanding Pediatric Caretakers’ Views on Obtaining Medical Care for Low‐acuity Illness

Background

A significant proportion of low‐acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low‐acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers’ perspectives. The objective of this study was to explore caretaker decision‐making processes, values, and priorities when deciding to seek care.

Methods

We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing.

Results

Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision‐making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low‐acuity care was well received by caretakers.

Conclusions

Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low‐acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.

     

Outcomes of Patients With Syncope and Suspected Dementia

Objectives

Syncope and near‐syncope are common in patients with dementia and a leading cause of emergency department (ED) evaluation and subsequent hospitalization. The objective of this study was to describe the clinical trajectory and short‐term outcomes of patients who presented to the ED with syncope or near‐syncope and were assessed by their ED provider to have dementia.

Methods

This multisite prospective cohort study included patients 60 years of age or older who presented to the ED with syncope or near‐syncope between 2013 and 2016. We analyzed a subcohort of 279 patients who were identified by the treating ED provider to have baseline dementia. We collected comprehensive patient‐level, utilization, and outcomes data through interviews, provider surveys, and chart abstraction. Outcome measures included serious conditions related to syncope and death.

Results

Overall, 221 patients (79%) were hospitalized with a median length of stay of 2.1 days. A total of 46 patients (16%) were diagnosed with a serious condition in the ED. Of the 179 hospitalized patients who did not have a serious condition identified in the ED, 14 (7.8%) were subsequently diagnosed with a serious condition during the hospitalization, and an additional 12 patients (6.7%) were diagnosed postdischarge within 30 days of the index ED visit. There were seven deaths (2.5%) overall, none of which were cardiac‐related. No patients who were discharged from the ED died or had a serious condition in the subsequent 30 days.

Conclusions

Patients with perceived dementia who presented to the ED with syncope or near‐syncope were frequently hospitalized. The diagnosis of a serious condition was uncommon if not identified during the initial ED assessment. Given the known iatrogenic risks of hospitalization for patients with dementia, future investigation of the impact of goals of care discussions on reducing potentially preventable, futile, or unwanted hospitalizations while improving goal‐concordant care is warranted.

     

Effectiveness of a Specialized Brief Intervention for At‐risk Drinkers in an Emergency Department: Short‐term Results of a Randomized Controlled Trial

Background

Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have been developed, evaluated, and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (EDs) has not been clearly established.

Objective

We aimed to evaluate the feasibility and efficacy of an SBIRT program conducted by highly specialized professionals in the ED of a tertiary hospital.

Methods

We conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT program conducted by alcohol specialists for at‐risk drinkers presenting to the ED, measured with the three‐item version of the Alcohol Use Disorder Identification Test (AUDIT‐C). Patients were randomized to two groups, with the control group receiving two leaflets—one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. The primary outcomes were the proportion of at‐risk alcohol use measured by AUDIT‐C scale and the proportion of patients attending specialized treatment at 1.5 months.

Results

Of 3,027 patients presenting to the ED, 2,044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at‐risk drinking, and 200 agreed to participate. Seventy‐two percent of the participating sample were men, and the mean (±SD) age was 43 (±16.7) years. Follow‐up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption and fewer patients continuing with at‐risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also increased the probability of attending specialized treatment, compared to the control condition (23% vs. 9.8%, p = 0.0119)

Conclusion

The SBIRT program in the ED was found to be feasible and effective in identifying at‐risk drinkers, reducing at‐risk alcohol use, and increasing treatment for alcohol problems.

     

Homelessness and Emergency Medicine: A Review of the Literature

Objectives

We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence‐based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research.

Methods

We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross‐referencing bibliographies of the retrieved publications. Peer‐reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature.

Results

Twenty‐eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence‐based management of homeless ED patients.

Conclusion

Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease‐oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence‐based treatment strategies in caring for this vulnerable population.

     

Accuracy of Computed Tomography in Diagnosis of Intra‐abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta‐analysis

Background

Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined.

Objectives

The objective was to evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER‐LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient?

Methods

We searched PubMed, Embase, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and inpatient observation in those who were managed nonoperatively. In those who underwent LAP, THER‐LAP was considered as disease positive. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS‐2) to evaluate the risk of bias and assess the applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR–) using a random‐effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model.

Results

Seven studies were included encompassing 575 patients. The weighted prevalence of THER‐LAP was 34.3% (95% confidence interval [CI] = 30.5%–38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity = 50% to 100%, specificity = 39% to 97%, LR+ = 1.0 to 15.7, and LR– = 0.07 to 1.0. The high heterogeneity (I² > 75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated.

Discussion

The articles revealed a high prevalence (8.7%, 95% CI = 6.1%–12.2%) of injuries requiring THER‐LAP in patients with a negative CT scan and almost half (47%, 95% CI = 30%–64%) of those injuries involved the small bowel.

Conclusions

In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.

     

Change in Care Transition Practice for Patients With Nonspecific Chest Pain After Emergency Department Evaluation 2006 to 2012

Objectives

From 2005 to 2010 health care financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with nonspecific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients’ management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized that there is a decline in inpatient admission rates for patients with nonspecific CP after ED evaluation.

Methods

We retrospectively used the Nationwide ED Sample to quantify total and annual inpatient hospital admission rates from 2006 to 2012 for patients with a final ED diagnosis of nonspecific CP. We assessed the change in admission rates over time and stratified by facility characteristics including safety‐net hospital status, U.S. geographic region, urban/teaching status, trauma‐level designation, and hospital funding status.

Results

The admission rate for all patients with a final ED diagnosis of nonspecific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates.

Conclusion

There was a 41.1% decline in inpatient hospital admission for patients with nonspecific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.

     

Assessing the Effect of a Medical Toxicologist in the Care of Rattlesnake‐envenomated Patients

Background

Rattlesnake envenomation is an important problem in the United States, and the management of these envenomations can be complex. Despite these complexities, however, the majority of such cases are managed without the involvement of a medical toxicologist. The primary objective of this study was to evaluate the impact of a medical toxicology service (MTS) on the length of stay (LOS) of such patients.

Methods

The authors conducted a retrospective study at six centers in California. Patients were included if they were admitted in the 2 years before the establishment of a MTS (pre‐MTS) or in the 2 years after the creation of a MTS (post‐MTS).

Results

A total of 300 subjects were included (169 pre‐MTS, 131 post MTS). Baseline characteristics between the pre‐MTS and post‐MTS groups were very similar. The creation of a MTS was associated with a significant reduction in the mean (95% confidence interval) LOS (69.5 [59.1–79.9] hours vs. 48.1 [41.4–54.8] hours). This reduced LOS was not associated with any statistically significant change in readmission rates.

Conclusion

Rattlesnake bite patients treated by a medical toxicologist have a significantly reduced LOS compared to those without direct involvement of a medical toxicologist.

     

Comparing Statewide and Single‐center Data to Predict High‐frequency Emergency Department Utilization Among Patients With Asthma Exacerbation

Background

Previous studies examining high‐frequency emergency department (ED) utilization have primarily used single‐center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high‐frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single‐center data.

Methods

To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High‐frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single‐center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike's Information Criterion scores, 10‐fold cross‐validation, and receiver operating characteristic curves.

Results

Among children, high‐frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10‐fold cross‐validation for children was 0.70 (95% confidence interval [CI] = 0.69–0.72), compared to 0.71 (95% CI = 0.69–0.72) in the single‐center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76–0.77) and 0.76 (95% CI = 0.75–0.77), respectively.

Conclusion

Data available at the index ED visit can predict subsequent high‐frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single‐center).

     

Patient‐level Factors and the Quality of Care Delivered in Pediatric Emergency Departments

Objective

Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient‐level factors.

Methods

This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect.

Results

In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (–0.65 points in quality, 95% confidence interval [CI] = –1.24 to –0.06) and upper respiratory symptoms (–0.68 points in quality, 95% CI = –1.30 to –0.07).

Conclusion

We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.

     

Patient Preferences for Diagnostic Testing in the Emergency Department: A Cross‐sectional Study

Background

Diagnostic testing is common during emergency department (ED) visits. Little is understood about patient preferences for such testing. We hypothesized that a patient's willingness to undergo diagnostic testing is influenced by the potential benefit, risk, and personal cost.

Methods

We conducted a cross sectional survey among ED patients for diagnostic testing in two hypothetical scenarios: chest pain (CP) and mild traumatic brain injury (mTBI). Each scenario defined specific risks, benefits, and costs of testing. The odds of a participant desiring diagnostic testing were calculated using a series of nested multivariable logistic regression models.

Results

Participants opted for diagnostic testing 68.2% of the time, including 69.7% of CP and 66.7% of all mTBI scenarios. In the CP scenario, 81% of participants desired free testing versus 59% when it was associated with a $100 copay (difference = 22%, 95% confidence interval [CI] = 16% to 28%). Similarly, in the mTBI scenario, 73% of adult participants desired free testing versus 56% when charged a $100 copayment (difference = 17%, 95% CI = 11% to 24%). Benefit and risk had mixed effects across the scenarios. In fully adjusted models, the association between cost and desire for testing persisted in the CP (odds ratio [OR] = 0.33, 95% CI = 0.23 to 0.47) and adult mTBI (OR = 0.47, 95% CI = 0.33 to 0.67) scenarios.

Conclusions

In this ED‐based study, patient preferences for diagnostic testing differed significantly across levels of risk, benefit, and cost of diagnostic testing. Cost was the strongest and most consistent factor associated with decreased desire for testing.

     

Effectiveness of Implementing Evidence‐based Interventions to Reduce C‐spine Image Ordering in the Emergency Department: A Systematic Review

Objectives

Appropriate use of imaging for adult patients with cervical spine (C‐spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C‐spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence‐based interventions aimed at reducing C‐spine imaging in adults presenting to the ED with neck trauma.

Methods

Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects.

Results

A total of 990 unique citations were screened for relevance of which six before–after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C‐spine rule. Overall, implementation of interventions aimed at reducing C‐spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69, 95% CI = 0.51–0.93); however, heterogeneity was high (I² = 82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p = 0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p = 0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported.

Conclusion

There is moderate evidence regarding the effectiveness of interventions to reduce C‐spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C‐spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted.

     

Air Ambulance Delivery and Administration of Four‐factor Prothrombin Complex Concentrate Is Feasible and Decreases Time to Anticoagulation Reversal

Objectives

The objective was to evaluate the feasibility, safety, and preliminary efficacy of four‐factor prothrombin complex concentrate (4‐factor PCC) administration by an air ambulance service prior to or during transfer of patients with warfarin‐associated major hemorrhage to a tertiary care center for definitive management (interventional arm) compared to patients receiving 4‐factor PCC following transfer by air ambulance or ground without 4‐factor PCC treatment (conventional arm).

Methods

This was a retrospective chart review of patients presenting to a large academic medical center. All patients presenting to the emergency department (ED) treated with 4‐factor PCC from April 1, 2014, through June 30, 2016, were identified. For this study, only transfer patients with an International Normalized Ratio (INR) > 1.5 actively treated with warfarin were included. The primary outcome was the proportion of patients with an INR ≤ 1.5 upon tertiary care hospital arrival, and the secondary efficacy outcome was difference in time to achievement of INR ≤ 1.5. Additional safety and efficacy objectives included difference in thromboembolic complications, length of stay, intensive care unit length of stay, and inpatient mortality between groups.

Results

Of the 72 included patients, a higher proportion of patients in the interventional group had an INR ≤ 1.5 on ED arrival (proportion difference = 0.82, 95% confidence interval = 0.64–0.92, p < 0.0001) and significantly reduced time to observed INR ≤ 1.5 (181 minutes vs. 541 minutes, p = 0.001). No differences were observed in thromboembolic complications or patient‐centered outcomes with the exception of mortality, which was significantly higher in patients in the interventional group. This group was also observed to have lower Glasgow Coma Scale score and higher intubation rates prior to transfer and treatment.

Conclusions

Dispatch of an air ambulance carrying 4‐factor PCC with administration prior to transfer is feasible and leads to more rapid improvement in INR among patients with warfarin‐associated major hemorrhage.

     

“What Do People Do If They Don't Have Insurance?”: ED‐to‐ED Referrals

Objective

Up to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore 1) whether patients making a repeat ED visit are self‐referred or indirectly referred from the other ED and 2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits.

Methods

This mixed‐methods study conducted over a 10‐week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint. Selected patients presenting with fractures were then enrolled for semistructured qualitative interviews, which were audiotaped, transcribed, and independently coded by two team members until thematic saturation was reached.

Results

A total of 143 patients were identified as being recently seen at another local ED for the same chief complaint prior to presenting to the public hospital; 94% were uninsured and 61% presented with fractures. A total of 27% required admission at the public ED and 95% of those discharged required further outpatient follow‐up. Fifty‐one percent of patients completed a survey and qualitative interviews were conducted with 23 fracture patients. Fifty‐three percent of patients reported that staff at the first hospital told them to go the public hospital ED, and 23% reported referral from a follow‐up physician associated with the first hospital. Seventy‐three percent reported receiving the same tests at both EDs. Interview themes identified multiple health care visits for the same injury, concern about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow‐up care without insurance, loss of work, and financial strain.

Conclusions

The majority of patients presenting to a public hospital ED after treatment for the same complaint in another local ED were indirectly referred to the public ED without transferring paperwork or records, incurring duplicate testing and patient anxiety.

     

Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta‐analysis

Objectives

Pain is a common complaint in the emergency department (ED). Its management currently depends heavily on pharmacologic treatment, but evidence suggests that nonpharmacologic interventions may be beneficial. The purpose of this systematic review and meta‐analysis was to assess whether nonpharmacologic interventions in the ED are effective in reducing pain.

Methods

We conducted a systematic review of the literature on all types of nonpharmacologic interventions in the ED with pain reduction as an outcome. We performed a qualitative summary of all studies meeting inclusion criteria and meta‐analysis of randomized controlled studies measuring postintervention changes in pain. Interventions were divided by type into five categories for more focused subanalyses.

Results

Fifty‐six studies met inclusion criteria for summary analysis. The most studied interventions were acupuncture (10 studies) and physical therapy (six studies). The type of pain most studied was musculoskeletal pain (34 studies). Most (42 studies) reported at least one improved outcome after intervention. Of these, 23 studies reported significantly reduced pain compared to control, 24 studies showed no difference, and nine studies had no control group. Meta‐analysis included 22 qualifying randomized controlled trials and had a global standardized mean difference of –0.46 (95% confidence interval = –0.66 to –0.27) in favor of nonpharmacologic interventions for reducing pain.

Conclusion

Nonpharmacologic interventions are often effective in reducing pain in the ED. However, most existing studies are small, warranting further investigation into their use for optimizing ED pain management.

     

Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines

Objective

Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture.

Methods

We conducted a pre–post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre‐ and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing.

Results

There were 508,337 pre‐ and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR] = 0.89, 95% CI = 0.87–0.91) and a decrease in the monthly trend compared to the preintervention period (OR = 0.99, 95% CI = 0.99–0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR = 0.81, 95% CI = 0.72–0.91), whereas the fracture cohort showed no change (OR = 1.10, 95% CI = 0.97–1.25).

Conclusion

The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.

     

A Qualitative Analysis of Patients’ Perceptions of Shared Decision Making in the Emergency Department: “Let Me Know I Have a Choice”

Background and Objectives

Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients’ perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients’ desired level of involvement and what barriers and facilitators patients find most relevant to their experience.

Methods

We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three‐person coding team. Emergent themes were identified, discussed, and organized.

Results

Twenty‐nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self‐efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians’ good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care.

Conclusions

This exploration of ED patients’ perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.

     

Scapular Fractures in the Pan‐scan Era

Background

Scapular fractures have been traditionally taught to be associated with significant injuries and major morbidity. As we demonstrated with sternal fracture, pulmonary contusion, and rib fracture, increased chest computed tomography (CT) utilization and head‐to‐pelvis CT (pan‐scan) protocols in blunt trauma evaluation, however, may diagnose minor, clinically irrelevant scapular fractures, possibly rendering previous teachings obsolete.

Objectives

The objectives were to determine the 1) percentages of scapular fractures seen on chest CT only (SOCTO) versus seen on both chest x‐ray (CXR) and CT and of isolated scapular fracture (scapular fracture without other thoracic injuries); 2) frequencies of associated thoracic injury with scapular fracture; and 3) proportion of patients admitted, mortality, hospital length of stay, and injury severity scores (ISS), comparing four patient groups: scapular fracture, nonscapular fracture, scapular fracture SOCTO, and isolated scapular fracture.

Methods

We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest CT study at nine Level I trauma centers with the following inclusion criteria: age > 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation.

Results

Of 11,477 subjects, 4,501 (39.2%) patients who had both CXR and chest CT and 2.7% of these had scapular fractures; 60.3% of these were SOCTO and 23 (19.0%) were isolated scapular fracture. The most commonly associated thoracic injuries were rib fracture, pulmonary contusion, pneumothorax, and thoracic spine fracture and all injuries were more common in scapular fracture patients than nonscapular fracture patients. Although scapular fracture patients had higher admission rates (86.8% vs. 47.4%; difference in proportions = 39.4% [95% confidence interval {CI} = 32.8% to 44.1%]), ISS (21 vs. 5), and length of stay (9.2 days vs. 5.6 days; mean difference = 3.4 days [95% CI = 2.1 to 4.7 days]) than patients without scapular fracture, their hospital mortality was not significantly different (5.6% vs. 3.0%; difference in proportions = 2.6% [95% CI = –8.2% to 0.3%]; unadjusted odds ratio = 1.9 [95% CI = 0.9 to 4.2]). Patients with scapular fracture SOCTO and isolated scapular fracture had higher admission rates and median ISS than nonscapular fracture patients, but their mortality was similar.

Conclusions

Under current blunt trauma imaging protocols that commonly include chest CT, most scapular fractures are SOCTO and most are associated with other thoracic injuries. Although patients with scapular fracture SOCTO and isolated scapular fracture have higher admission rates and ISS than nonscapular fracture patients, their hospital mortality is similar.