Characteristics and Health Care Utilization of Patients With Housing Insecurity in the ED

Importance

Unstable housing and homelessness can exacerbate adverse health outcomes leading to increased risk of chronic disease, injury, and disability. However, emergency departments (EDs) have no universal method to identify those at risk of or currently experiencing homelessness.

Objective

To describe the extent of housing insecurity among patients who seek care in an urban ED, including chief concerns, demographics, and patterns of health care utilization.

Design, Setting, and Participants

This cross-sectional study included all adult patients presenting to the ED at Vanderbilt University Medical Center (VUMC), an urban tertiary care, level I trauma center in the Southeast US, from January 5 to May 16, 2023.

Main Outcomes and Measures

The primary outcome was the proportion of ED visits at which patients screened positive for housing insecurity. Secondary outcomes included prevalence of insecurity by chief concerns, demographics, and patterns of health care utilization.

Results

Of all 23 795 VUMC ED visits with screenings for housing insecurity (12 465 visits among women [52%]; median age, 47 years [IQR, 32-48 years]), in 1185 (5%), patients screened positive for current homelessness or housing insecurity (660 unique patients); at 22 610 visits (95%), the screening result was negative. Of visits with positive results, the median age of patients was 46 years (IQR, 36-55 years) and 829 (70%) were among male patients. Suicide and intoxication were more common chief concerns among visits at which patients screened positive (132 [11%] and 118 [10%], respectively) than among those at which patients screened negative (220 [1%] and 335 [2%], respectively). Visits with positive results were more likely to be among patients who were uninsured (395 [33%] vs 2272 [10%]) and had multiple visits during the study period. A higher proportion of positive screening results occurred between 8 pm and 6 am. The social work team assessed patients at 919 visits (78%) with positive screening results.

Conclusions and Relevance

In this cross-sectional study of 23 795 ED visits, at 5% of visits, patients screened positive for housing insecurity and were more likely to present with a chief concern of suicide, to be uninsured, and to have multiple visits during the study period. This analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity to achieve equitable health care.

Characteristics and outcomes of prehospital and emergency department surgical airways

Objectives

The surgical airway is a high acuity, low occurrence procedure. Data on the complications and outcomes of surgical airways are limited. Our primary objective was to describe immediate complications, late complications, and clinical outcomes of patients who underwent a surgical airway procedure in the prehospital or emergency department (ED) setting.

Methods

We conducted a retrospective chart review of patients ≥14 years at an academic medical center who underwent a surgical airway procedure in the ED, the prehospital setting, or at a referring ED prior to interfacility transfer. We identified cases from keyword searches of prehospital text pages and hospital electronic medical records from June 1, 2008 to July 1, 2022. Manual chart review was used to confirm inclusion and determine patient and procedure characteristics. Outcomes included immediate complications, delayed in-hospital complications, and neurologic disability as defined by Modified Rankin Score (mRS) at discharge.

Results

We identified 63 patients (34 prehospital, 11 ED, and 18 referring ED). Immediate complications included mainstem intubation (46.0%) and bleeding that required direct pressure (23.4%). Overall, 29 patients (46%) died after arrival to the hospital. Of the patients surviving to hospital admission, 25 (48%) had an airway-related complication. Nine complications were deemed directly related to technical components of the procedure. Of the patients who survived to discharge, 18 (52.9%) had poor neurologic function (mRS 4-5).

Conclusion

Procedural complications, mortality, and poor neurologic function were common following a surgical airway procedure in the prehospital or ED setting. Most patients surviving to discharge had a moderate to severe neurologic disability.

Injuries From Legal Interventions Involving Conducted Energy Devices

This cross-sectional study evaluates emergency department visits for physical injuries from use of conducted energy devices by police departments.

Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis

Objectives

Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from epinephrine treatment for anaphylaxis is not well described. We sought to describe the frequency of cardiotoxicity following intramuscular (IM) administration of epinephrine in adult emergency department (ED) patients with anaphylaxis.

Methods

We conducted a retrospective observational study at a single, quaternary care academic ED in Tennessee. We identified consecutive ED visits with the diagnosis of anaphylaxis from 2017 to 2021 who received at least one intramuscular (IM) dose of epinephrine in the ED. Analysis was primarily descriptive. The primary outcome was cardiotoxicity, the occurrence of any of the following after epinephrine administration: ischemic electrocardiogram changes, systolic blood pressure >200 mmHg, or cardiac arrest ≤4 h; elevated troponin ≤12 h; or percutaneous coronary intervention or depressed ejection fraction ≤72 h.

Results

Among 338 included patients, 16 (4.7%; 95%CI: 2.8-7.6%) experienced cardiotoxicity. Cardiotoxic events included eight (2.4%) ischemic electrocardiogram changes, six (1.8%) episodes of elevated troponin, five (1.5%) atrial arrhythmias, one (0.3%) ventricular arrythmia, and one (0.3%) depressed ejection fraction. Patients with cardiotoxicity were significantly older, had more comorbidities, and were more likely to have received multiple doses of epinephrine or an epinephrine infusion compared with a single IM dose of epinephrine.

Conclusions

Among 338 consecutive adult ED patients who received IM epinephrine for anaphylaxis during a recent 4-year period, cardiotoxic side effects were observed in approximately 5% of patients.

Limitations in the use of automated mental status detection for clinical decision support

BACKGROUND

Clinical decision support (CDS) tools improve adherence to evidence-based practices but are dependent upon data quality in the electronic health record (EHR). Mental status is an integral component of many risk stratification scores, but it is not known whether EHR-measures of altered mental status are reliable. The Glasgow Coma Scale (GCS) is a measure of altered mentation that is widely adopted and entered in the EHR in structured format. We sought to determine the accuracy GCS < 15 as an EHR-measure of altered mentation compared to ED provider documentation.

METHODS

In patients presenting to an academic Emergency Department (ED) with pneumonia we abstracted GCS values entered by nurses during routine care and in a randomly selected subset manually reviewed provider documentation for evidence of altered mental status. We defined eConfusion as present if GCS < 15 at any point during the ED encounter. We then calculated the CURB-65 score and corresponding suggested disposition using each method. Performance of eConfusion and corresponding CURB-65 compared to manual versions was measured using agreement (Cohen's K), sensitivity, and specificity.

RESULTS

Among 300 randomly selected encounters, 47 (16 %) had eConfusion present and 46 (15 %) had evidence of altered mental status in provider documentation with Cohen's K 0.73. eConfusion had 78 % sensitivity and 96 % specificity for provider documented altered mental status. When input into CURB-65 to recommend inpatient disposition, eConfusion had 95 % sensitivity, and recommended discordant disposition for 3 %.

CONCLUSIONS

There was modest agreement between eConfusion and provider documentation of altered mental status. eConfusion had good specificity but low sensitivity which resulted in under-estimation of the CURB-65 score and occasional inappropriate disposition recommendations compared to provider documentation. These data do not support the use of GCS as a measure for altered mentation for use in CDS tools in the ED.

Randomized controlled trial of urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE): Rationale and design

Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple clinical trials have investigated initial diuretic strategies for a designated period of time, there is a paucity of evidence to guide diuretic titration strategies continued until decongestion is achieved. The use of urine chemistries (urine sodium and creatinine) in a natriuretic response prediction equation accurately estimates natriuresis in response to diuretic dosing, but a randomized clinical trial is needed to compare a urine chemistry-guided diuresis strategy with a strategy of usual care. The urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE) trial is designed to test the hypothesis that protocolized diuretic therapy guided by spot urine chemistry through completion of intravenous diuresis will be superior to usual care and improve outcomes over the 14 days following randomization. ESCALATE will randomize and obtain complete data on 450 patients with acute heart failure to a diuretic strategy guided by urine chemistry or a usual care strategy. Key inclusion criteria include an objective measure of hypervolemia with at least 10 pounds of estimated excess volume, and key exclusion criteria include significant valvular stenosis, hypotension, and a chronic need for dialysis. Our primary outcome is days of benefit over the 14 days after randomization. Days of benefit combines patient symptoms captured by global clinical status with clinical state quantifying the need for hospitalization and intravenous diuresis. CLINICAL TRIAL REGISTRATION: NCT04481919.

Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial

Importance

Cefepime and piperacillin-tazobactam are commonly administered to hospitalized adults for empirical treatment of infection. Although piperacillin-tazobactam has been hypothesized to cause acute kidney injury and cefepime has been hypothesized to cause neurological dysfunction, their comparative safety has not been evaluated in a randomized clinical trial.

Objective

To determine whether the choice between cefepime and piperacillin-tazobactam affects the risks of acute kidney injury or neurological dysfunction.

Design, Setting, and Participants

The Antibiotic Choice on Renal Outcomes (ACORN) randomized clinical trial compared cefepime vs piperacillin-tazobactam in adults for whom a clinician initiated an order for antipseudomonal antibiotics within 12 hours of presentation to the hospital in the emergency department or medical intensive care unit at an academic medical center in the US between November 10, 2021, and October 7, 2022. The final date of follow-up was November 4, 2022.

Interventions

Patients were randomized in a 1:1 ratio to cefepime or piperacillin-tazobactam.

Main Outcomes and Measures

The primary outcome was the highest stage of acute kidney injury or death by day 14, measured on a 5-level ordinal scale ranging from no acute kidney injury to death. The 2 secondary outcomes were the incidence of major adverse kidney events at day 14 and the number of days alive and free of delirium and coma within 14 days.

Results

There were 2511 patients included in the primary analysis (median age, 58 years [IQR, 43-69 years]; 42.7% were female; 16.3% were Non-Hispanic Black; 5.4% were Hispanic; 94.7% were enrolled in the emergency department; and 77.2% were receiving vancomycin at enrollment). The highest stage of acute kidney injury or death was not significantly different between the cefepime group and the piperacillin-tazobactam group; there were 85 patients (n = 1214; 7.0%) in the cefepime group with stage 3 acute kidney injury and 92 (7.6%) who died vs 97 patients (n = 1297; 7.5%) in the piperacillin-tazobactam group with stage 3 acute kidney injury and 78 (6.0%) who died (odds ratio, 0.95 [95% CI, 0.80 to 1.13], P = .56). The incidence of major adverse kidney events at day 14 did not differ between groups (124 patients [10.2%] in the cefepime group vs 114 patients [8.8%] in the piperacillin-tazobactam group; absolute difference, 1.4% [95% CI, -1.0% to 3.8%]). Patients in the cefepime group experienced fewer days alive and free of delirium and coma within 14 days (mean [SD], 11.9 [4.6] days vs 12.2 [4.3] days in the piperacillin-tazobactam group; odds ratio, 0.79 [95% CI, 0.65 to 0.95]).

Conclusions and Relevance

Among hospitalized adults in this randomized clinical trial, treatment with piperacillin-tazobactam did not increase the incidence of acute kidney injury or death. Treatment with cefepime resulted in more neurological dysfunction.

Trial Registration

ClinicalTrials.gov Identifier: NCT05094154.

Trends in paediatric firearm-related encounters during the COVID-19 pandemic by age group, race/ethnicity and schooling mode in Tennessee

BACKGROUND

Increases in paediatric firearm-related injuries during the COVID-19 pandemic may be due to changes in where children and adolescents spent their time. This study examines changes in the frequency of paediatric firearm-related encounters as a function of schooling mode overall and by race/ethnicity and age group at a large trauma centre through 2021.

METHODS

We use data from a large paediatric and adult trauma centre in Tennessee from January 2018 to December 2021 (N=211 encounters) and geographically linked schooling mode data. We use Poisson regressions to estimate smoothed monthly paediatric firearm-related encounters as a function of schooling mode overall and stratified by race and age.

RESULTS

Compared with pre pandemic, we find a 42% increase in paediatric encounters per month during March 2020 to August 2020, when schools were closed, no significant increase during virtual/hybrid instruction, and a 23% increase in encounters after schools returned to in-person instruction. The effects of schooling mode are heterogeneous by patient race/ethnicity and age. Encounters increased among non-Hispanic black children across all periods relative to pre pandemic. Among non-Hispanic white children, encounters increased during the closure period and decreased on return to in-person instruction. Compared with pre pandemic, paediatric firearm-related encounters increased 205% for children aged 5-11 and 69% for adolescents aged 12-15 during the school closure period.

CONCLUSION

COVID-19-related changes to school instruction mode in 2020 and 2021 are associated with changes in the frequency and composition of paediatric firearm-related encounters at a major trauma centre in Tennessee.

COVID-19 severity from Omicron and Delta SARS-CoV-2 variants

The Omicron variant of SARS-CoV-2 achieved worldwide dominance in late 2021. Early work suggests that infections caused by the Omicron variant may be less severe than those caused by the Delta variant. We sought to compare clinical outcomes of infections caused by these two strains, confirmed by whole genome sequencing, over a short period of time, from respiratory samples collected from SARS-CoV-2 positive patients at a large medical center. We found that infections caused by the Omicron variant caused significantly less morbidity, including admission to the hospital and requirement for oxygen supplementation, and significantly less mortality than those caused by the Delta variant.

Quantifying clinical narrative redundancy in an electronic health record

OBJECTIVE

Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR.

DESIGN AND METHODS

We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes.

MEASUREMENTS

We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents.

RESULTS

Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note).

CONCLUSION

The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.

What "to-do" with physician task lists: clinical task model development and electronic health record design implications

Clinical task, or "to-do" lists are a common element in the physician document known as signout. Such lists are used to capture and track patient care plan items, supporting daily workflow and collaborative patient management continuity across care transitions. While physician task lists have been shown to be important to patient safety, the tasks themselves have not been systematically examined for their subject matter, structure, or components. A manual sublanguage analysis of 500 signout tasks was conducted, and a hierarchical conceptual model for clinical tasks was inductively constructed. Tasks were classified by action type (Assess, Order, Communicate, Perform) and corresponding components. The most common task action types were Assess and Order. The most common task components were "What" type components such as Tests, including subtypes Laboratory and Imaging. This study yielded several important design considerations for future electronic health record systems that support collaborative clinical task management.

Signout: a collaborative document with implications for the future of clinical information systems

Signout is an unofficial clinical document used traditionally to facilitate patient handoff. Qualitative studies have suggested its importance in clinical care. We used a novel technique to quantify the use of signout by analyzing clinical information system logfiles. Viewing and editing events were collected for 1,677 unique patients admitted to our internal medicine service. We found the average patient's signout on a given day is viewed frequently (>6x) and edited frequently (>2x) with multiple unique viewers (>3) and editors (>1). We also found that signouts are used throughout a 24-hour period, not just at the time of handoff. Finally, we showed that they are viewed months and even years after their creation. Signout is therefore a highly utilized, collaborative, clinical document used for more than patient handoff. Our findings also suggest that clinical information systems may benefit from the introduction of collaborative tools such as subscription, versioning, and author-attribution utilities.

An unsupervised machine learning approach to segmentation of clinician-entered free text

Natural language processing, an important tool in biomedicine, fails without successful segmentation of words and sentences. Tokenization is a form of segmentation that identifies boundaries separating semantic units, for example words, dates, numbers and symbols, within a text. We sought to construct a highly generalizeable tokenization algorithm with no prior knowledge of characters or their function, based solely on the inherent statistical properties of token and sentence boundaries. Tokenizing clinician-entered free text, we achieved precision and recall of 92% and 93%, respectively compared to a whitespace token boundary detection algorithm. We classified over 80% of punctuation characters correctly, based on manual disambiguation with high inter-rater agreement (kappa=0.916). Our algorithm effectively discovered properties of whitespace and punctuation in the corpus without prior knowledge of either. Given the dynamic nature of biomedical language, and the variety of distinct sublanguages used, the effectiveness and generalizability of our novel tokenization algorithm make it a valuable tool.