Abstracts for the 40th Emergencies in Medicine Conference (2022)

Relationships between Emergency Department Wait Times in the United States Nicholas Peterman, Gweniviere Capron1, Bradley Kaptur, Andrew Roberts1, Jacques Lowe, Faran Bokhari1,2 Emergency Department, Carle Illinois College of Medicine, University of Illinois, Urbana-Champaign, Urbana, 1Department of Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, 2Department of Surgery, Carle Foundation Hospital, Urbana, IL Background: Previous work has shown that admissions with longer wait times have worse clinical outcomes. Factors influencing emergency department (ED) wait times have been of great interest to researchers, as well as the associated increased morbidity and mortality. There is a gap in the literature in categorizing the extent of these delays and their related statistically significant factors. Methods: The United States Census and Centers for Medicare Service (CMS) public data from 2015 to 2019 were utilized. County-level travel time to an ED was calculated from network-based road analysis and then combined with the CMS ED wait time metrics to determine the total wait time to care. 2607 counties were sorted into high and low total wait time to care clusters and then compared using an analysis of variance (ANOVA) across 39 county-level health and socioeconomic variables to determine national disparities. Results: Moran’s I cluster analysis identified significant geospatial clusters in ED total wait to care times. 305 counties mostly in the East Coast, West Coast, and Rocky Mountain regions were designated high total wait time to care clusters with an average of 208.76 ± 46.44 min. 605 low total wait time to care clusters were found in the plains and mid-western regions, with a total of 126.22 ± 19.08 min. In factorial ANOVA, Black and Hispanic people represented 7.86% and 6.51% of the population in the high cluster, with significantly fewer in the low cluster, 6.26% and 2.4%, respectively. Population density was also significant between the high and low clusters, with 1028.08 versus 81.1 people per square mile. While the percentage in poverty was notably not significant between high and low clusters, the median household income was $57,521.15 and $50,425.47, respectively. There was a large difference between high and low clusters in both total yearly ED visits (18,196 vs. 3932) and yearly ED visits per 1000 Medicare members (673 vs. 680). Conclusion: Despite previous work highlighting lack of access to physicians in rural areas, the decreased wait time of EDs in these areas is one metric where these areas have an advantage over their coastal counterparts. This is partially linked to the decreased ED volume in these regions. Many significant differences in the demographic variables of interest appear to largely delineate the overall rural–urban divide between these clusters. Keywords: Care delay, emergency department, time to care, wait time Real-World Utilization of Andexanet Alfa in the Management of Oral Factor Xa Inhibitor-Associated Gastrointestinal Bleeding Caitlin S. Brown, Alicia E. Mattson, Daniel Cabrera1, Nayantara Coelho-Prabhu2, Alejandro A. Rabinstein3, Terry Dettling4, Robert D. McBane5, Fernanda Bellolio1 Departments of Pharmacy and 1Emergency Medicine, Mayo Clinic, 2Division of Gastroenterology and Hepatology, Mayo Clinic, 3Division of Neurology, Mayo Clinic, 4Alexion/Astra Zeneca Rare Diseases, 5Division of Vascular Medicine, Mayo Clinic, Rochester, MN, USA Background: Andexanet alfa (AA) is approved for reversal of factor Xa inhibitor (FXaI) bleeds with the inclusion of gastrointestinal bleed (GIB) in The Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors-4 (ANNEXA-4) trial; however, there are limited reports of its use for GIB in real-world populations. This study aims to evaluate the effectiveness of AA for FXaI-associated GIB at an academic medical center. Methods: This was a case series of patients (pts) receiving AA for FXaI-associated GIB between July 2018 and February 2021. Baseline demographics, blood product administration, hemostasis, rebleeding, thrombosis, and mortality were collected. Hemostatic efficacy, consistent with ANNEXA-4 definition, was based on corrected hemoglobin at 12 h compared to baseline. Descriptive statistics were reported. Wilcoxon rank-signed test was used to compare the efficacy in pts undergoing procedures, and Fisher’s exact test was used to compare red blood cells (RBCs) received between efficacy groups. P < 0.05 was considered statistically significant, and all analyses were performed using RStudio Team (2020). RStudio: Integrated Development for R. RStudio, PBC, Boston, MA. Results: Twenty-two pts were included in the study. 63.6% were male and the median age was 76 years. Most pts (59.1%) were on apixaban, the primary indication for FXaI was atrial fibrillation (63.6%), and 45.5% of the pts had a cancer diagnosis. Median baseline hemoglobin was 7.5 g/dL, and the most common type of bleed was upper GIB (50.0%). A majority (77.3%) underwent a procedure, with endoscopy (76.0%) being the most common initial procedure. 45.5% of the pts had excellent, 22.7% had good, and 31.8% had poor hemostasis. In pts who underwent a procedure, there was no significant difference between good/excellent and poor hemostasis. There was no significant difference between RBCs received between pts in the good/excellent hemostasis group compared to the pts in poor hemostasis group. 13.6% of the pts had a rebleeding event, there was a 27.2% 30-day mortality rate, and two pts had arterial thrombotic events within 30 days of reversal. Conclusion: In this real-world analysis, AA provided excellent or good hemostasis in most pts with GIB with a 9% 30-day thrombotic event rate. The mortality rate was high in this cohort likely due to severity of illness. Due to the lack of a comparator group, it is difficult to draw strong conclusions, and hence, additional studies are needed. Keywords: Andexanet alfa, factor Xa inhibitor, gastrointestinal bleeds Healthcare Costs Reduction with Home Furoscix versus In-Hospital Intravenous Diuresis Daniel Bensimhon, William S. Weintraub1, W. Frank Peacock2, Tamas Alexy3, Dalton McLean, Donald Haas4, Kathleen L. Deering5, Matthew M. Goodwin6, John F. Mohr6 Cone Health, Greensboro, NC, 1MedStar Health Research Institute, Hyattsville, MD, 2Ben Taub Hospital, Houston, TX, 3University of Minnesota Medical Center, Minneapolis, MN, 4Abington Hospital, Abington, PA, 5EPI-Q, Inc., Oak Brook, IL; 6scPharmaceutIcals, Burlington MA, USA Background: Up to 90% of patients (pts) presenting to the emergency department (ED) with worsening heart failure (HF) are admitted, and 50% of these hospitalizations may be avoidable. Furoscix is a pH-neutral formulation of furosemide in the development for subcutaneous (SC) administration via an on-body drug delivery system. Furoscix is administered as an 80 mg SC dose over 5 h. It has demonstrated 99.6% bioavailability relative to the same dose of intravenous (IV) furosemide with comparable diuresis and natriuresis. The FREEDOM-HF study was designed to compare 30-day overall and HF-related costs in ED pts with congestion who were discharged with SC Furoscix versus matched comparators admitted for IV diuretics. Methods: This was a multicenter, prospective study of chronic HF pts presenting to the ED with worsening congestion despite oral diuretic therapy. Pts were discharged on Furoscix for up to 7 days and followed for 30 days. Comparators were hospitalized for ≤72 h and selected from a claim database matched to seven variables associated with HF hospitalization and severity. Overall and HF-related costs, including HF hospitalizations and HF-related ED and clinic visits in 30 days, were derived from IBM® MarketScan® Commercial Claims and Medicare Supplemental Database. Cost benchmarks from the comparator population were applied to both groups. Results: Ninety subjects (24 Furoscix/66 comparators) were included. Overall mean (standard deviation) age was 57 (8.3) years, 57/90 (63%) were males, 51/90 (57%) had HF with reduced ejection fraction, 43/90 (48%) had HF hospitalization in the prior 6 months, 23/90 (26%) had Stage 3 chronic kidney disease, 33/90 (37%) had chronic obstructive pulmonary disease, and 62/90 (69%) had diabetics, with similar rates between groups. Overall and HF-related healthcare costs were significantly lower in the Furoscix group [Table 1]. Of pts discharged from the ED with Furoscix, only 1/24 (4.2%) had an HF-related hospitalization. In the comparator group, 7/66 (10.6%) had HF-related readmission within 30 days of initial discharge. There were 1 (4.2%) and 4 (6.1%) HF-related ED visits in the Furoscix and comparator groups, respectively. Conclusion: In ED HF pts with mild-to-moderate congestion despite the use of oral diuretics, discharge with SC Furoscix was associated with significantly reduced overall and HF-related healthcare costs through reduction of HF-related hospitalizations. Keywords: Diuresis, emergency department, Furoscix, furosemide, heart failure Quality of Life and Satisfaction with Furoscix in Heart Failure Patients Daniel Bensimhon, William S. Weintraub1, W. Frank Peacock2, Tamas Alexy3, Dalton McLean, Donald Haas4, Kathleen L. Deering5, Stefanie J Millar6, Matthew M. Goodwin7, John F. Mohr7 Cone Health, Greensboro, NC, 1MedStar Health Research Institute, Hyattsville, MD, 2Emergency Department, Ben Taub Hospital, Houston, TX, 3University of Minnesota Medical Center, Minneapolis, MN, 4Abington Hospital, Abington, PA, 5EPI-Q, Inc., Oak Brook, IL, 6ICON Clinical Research, North Wales, PA, 7scPharmaceuticals, Burlington, MA, USA Background: Furoscix (furosemide subcutaneous infusion) has demonstrated 99.6% bioavailability relative to the same dose of intravenous (IV) furosemide with comparable diuresis and natriuresis. In the FREEDOM-HF trial, patients (pts) with heart failure (HF) exacerbation who were managed as outpatients using Furoscix incurred lower mean HF-related and overall healthcare (all-cause) costs versus matched comparators who required hospital admission for IV diuresis. This study aims to explore the impact of Furoscix on biomarker levels and secondary endpoints of health-related quality of life and patient/caregiver satisfaction in HF pts discharged from the emergency department (ED). Methods: FREEDOM-HF trial was a multicenter, open-label study of chronic HF pts who presented to the ED with worsening congestion. Adults with New York Heart Association Class II–III symptoms, evidence of volume overload, stable vital signs, and a creatinine clearance >30 mL/min were eligible. Enrolled pts were discharged with Furoscix for up to 7 days and monitored for a total of 30 days. Health-related quality of life was evaluated via Kansas City Cardiomyopathy Questionnaire (KCCQ-12) at day 0 versus day 30, and B-type natriuretic peptide (BNP)/N-terminal NT-proBNP values were assessed at day 0, day 2–4, and day 30. Patient/caregiver satisfaction was measured with a Comfort of Wear Questionnaire on day 2–4. Results: Twenty-four (n = 24) pts were included in the open-label (Furoscix) arm of the study. The mean age was 56 ± 12.3 years, 15 (63%) were male, 14 (58%) had HF with reduced ejection fraction, 24 (63%) were hospitalized for HF within the prior 6 months, 6 (25%) had Stage 3 chronic kidney disease, and 12 (50%) had diabetes. Comparing baseline to day 30, Furoscix pts mean KCCQ-12 summary score increased from 29.9 to 42.8 (n = 21; P = 0.044) and the mean symptom score rose from 33.1 to 50.5 (n = 24; P = 0.004). Median natriuretic peptide levels were reduced from baseline to day 2–4 and day 30 by 42.3% and 28%, respectively (P < 0.01). Most (75%) pts felt comfortable wearing the device. Conclusion: In the FREEDOM-HF trial, pts with mild to moderately decompensated HF were able to avoid hospital admission and be safely discharged from the ED. This current analysis showed that treatment with Furoscix was also associated with clinically meaningful reductions in natriuretic peptides, marked improvement in quality of life, and pts reported satisfaction with the intervention. Keywords: FREEDOM-HF, Furoscix, furosemide, heart failure, patient satisfaction Comparison of Educational Methods during Virtual Lectures Jennifer Carnell, Ideen Zeinali, Lynea Bull, Fabi Martinuzzi, Yasien Eltigani, Giovanni Ramirez Emergency Department, Baylor College of Medicine, Houston, Texas, USA Background: The ongoing coronavirus disease of 2019 (COVID-19) pandemic has forced medical education to continue in a virtual space using video conference software. However, it can be challenging for speakers to make lectures interactive and promote audience participation. An audience response system (ARS) can enhance traditional lectures by enabling participants to interact anonymously with the educator’s presentation. By promoting continuous participation, the educator gets real-time feedback on the learners’ understanding. The purpose of the study is to compare a traditional format (facilitator-led interactivity) versus an ARS (Poll [email protected]) format in a virtual session for medical students. The objectives are to assess learners’ perception of the interactivity and level of engagement and to evaluate the comprehension of the lecture’s objectives by assessing performance in pre- and post-conference tests. Methods: Conducted an online virtual session about the use of ultrasound in trauma with fourth-year medical students. At the moment, two groups have participated in the are into ARS group (n = and the traditional format group (n = Results: score = from the ARS and traditional format groups were and P = score = from the ARS and the traditional format group were and P = no difference in the pre- and between the two groups. However, pre- and mean from the same group, the medical in the ARS group by compared to a of in the traditional format group. from 1 to in the showed that both groups had similar and of the In the ARS group, the from 1 to had a median of 5 in response to the was to use during the and to use in Conclusion: there are not data to assess there is a difference in between the however, continue to data from and assess for in the Keywords: response virtual to in a New Emergency Department John Emergency Department, University of Health USA Background: patient is to emergency department (ED) a be This study a system can be used to to patient Methods: used event to patient for a ED and to its on to to and of The baseline was based on the current ED and using patient and for the ED. The included age for care of Emergency patients through a medical clinical and times. Results: was patients were to the were and of patients were discharged from the to admission time was to by about time was reduced by to large in times Conclusion: on the the ED was able to and of for a ED. This be used by EDs a or an In the of this study healthcare and into and from a Keywords: Emergency department, patient wait time A Rare of as The University College of Medicine, University of Medicine, Hospital, USA There have been of coronavirus disease 2019 (COVID-19) and can with one that has been reported is there have been reported of in a case of a male who presented to the emergency department (ED) and was found to have with a The patient presented to the ED of a of and as well as for 3 was not for or In the of with or gastrointestinal received all including the type were not included and showed mild was for a the patient and and was and A and were real-time was was to the was and was was with and and was was well at can with and or are not for has been associated with and test make coronavirus a and can be and the of can be Due to its physicians high for patients with or as patients may medical Keywords: of in Medicare Patients in or Care A. R. D. S. E. A. W. W. F. Emergency Department, Healthcare Health, College of Medicine, Houston, Texas, USA Background: is a common the and of in care or care Methods: This was a study using Medicare was as or use or 14 days an and were assessed during the and up to and costs were assessed in matched and In patients with days was performed based on for Medicare the of chronic kidney disease, heart failure, or system Results: Of the of during or was The (n = underwent with an of days and versus versus with of patients were male, and for with mean P < costs of were vs. and vs. were by at and up to 1 patients up to 1 of patients had during or within 1 1 of with had hospitalizations. and of were a was times for during or within 1 of hospitalization was for during healthcare costs were times during Keywords: care, care, of on of in Patients Andrew Daniel The University of Kansas Medical Center, Kansas USA Background: patients for of all emergency department (ED) This population can significantly ED of A of this is related to the time required to assess via This study an to of creatinine and its on in patients receiving a with Methods: This was a quality improvement study at an care ED. The study in data analysis was for the to and to The patient population included all patients receiving a with in the ED. and were included ED to time and ED Results: ED with during the study of in the and 2019 in the creatinine increased from in the to in the patient with a creatinine had a statistically significant ED to time and ED Conclusion: The in increased of creatinine in was with a time to as well as a ED initial the use of however, Most the study in ED visits due to the coronavirus disease 2019 In the were decreased compared to prior years, in the were This likely the of the intervention. Keywords: of creatinine to for and The University of Kansas Medical Kansas USA Background: Emergency department (ED) to decreased quality of care, increased healthcare system costs, and for A significant of the time a patient in the ED is the to of total time to a 2018 national This study an at the time from to to the of by Methods: This is a study at a academic medical center. were from the medical for all patients in the ED and admitted to for 12 and 12 the of July The included and The primary was the time from ED to to the of by Results: academic and had a significant reduction in the time between ED for admission and of by The academic had an initial average time to of to improvement of the from to improvement of longer both pre- and Conclusion: This had the of the time between ED for admission and of by The consistent difference in time between academic and a of academic Keywords: Emergency department, of time to admission to The University of Kansas Medical Center, Kansas USA Background: The United States emergency patient and wait in worsening is to ED An initial at showed that of ED of for admitted patients the ED to of that time of total ED an ED to admission and had been Methods: The study was a study at an academic care ED. The study included one and two The in July analysis included pre- and The included and The patient population included all patients admitted to the from the ED. The primary of interest was the time from ED to to Results: admissions during the study of and the time from ED to to decreased from to an improvement of (P < of physicians demonstrated that all demonstrated statistically significant improvement (P < and that the by Conclusion: The in a in time from ED to to all relative improvement of In to this likely patient through and Keywords: Emergency department, of and The of W. Frank Baylor College of Medicine, Houston, Hospital, TX, of of Medical Center, MD, and Background: The study aims to evaluate the and of a in the clinical Methods: in performed a to Inc., in at seven United States healthcare A was presented on an the was in the to be the their included the use of the This was considered a and was from the this analysis, only one per was included. are presented as (standard with Results: were from seven across the the of the system in the patient care were and included of use or to a as similar or significant no impact or and on patient felt that patient was or significantly Conclusion: The use of a system was reported as to to a and was an improvement to and patient Keywords: in Emergency Department Patients with W. Frank E. for Research, Taub Department of Emergency Medicine, Houston, TX, Medical Health Research Health Inc., Research Inc., Inc., Background: for are for patients with there is evidence on the real-world impact of use in the emergency department (ED). This study to compare healthcare in and healthcare costs patients in the ED who not for Methods: ED patients were evaluated to and into based on received in the ED. were using to based on demographics, hospital and was assessed in the ED and for 30-day and costs were compared using with at the hospital were also assessed a of patients with Results: and patients were identified in the subcutaneous and respectively. overall mean age years, and Most patients were from or ED an patients were times likely to be discharged = P < and likely to be admitted as an = P < average of was 1 day P < for drug costs, patients had a mean of in total health care costs per ED including the ED through 30-day The were consistent the cancer where patients had a mean of P < in total healthcare costs per ED Conclusion: Patients receiving in the ED are likely to be discharged likely to be have a have a mean reduction of and days per ED patients not in the ED Keywords: emergency department,