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Loss to follow-up of enrolled patients (a.k.a. attrition) is a major threat to study validity and power. Minimizing attrition can be challenging even under ideal research conditions, including the presence of adequate funding, experienced study personnel, and a refined research infrastructure. Emergency care research is shifting toward enrollment through multisite networks, but there have been limited descriptions of approaches to minimize attrition for these multicenter emergency care studies. This concept paper describes a stepwise approach to minimize attrition, using a case example of a multisite emergency department prospective cohort of over 3,000 patients that has achieved a 30-day direct phone follow-up attrition rate of <3%. The seven areas of approach to minimize attrition in this study focused on patient selection, baseline contact data collection, patient incentives, patient tracking, central phone banks, local enrollment site assistance, and continuous performance monitoring. Appropriate study design, including consideration of these methods to reduce attrition, will be time well spent and may improve study validity. [ABSTRACT FROM AUTHOR]

Objectives: While immediate diagnosis and irrigation is standard chemical eye burn practice, it is unknown to what extent specific pH measurements influence management, given the frequent clinical availability of narrow‐spectrum nitrazine pH strips. We hypothesize that exclusive broad‐spectrum pH strip implementation leads to more accurate measurement and expedited ophthalmologic consultation. Methods: At a Level I trauma center over 25 months, all emergent adult ophthalmology consultations for chemical burns were included in a pre‐intervention (n = 22) and post‐intervention (n = 20) study design. During this time, narrow‐spectrum nitrazine pH strips available to non‐obstetric emergency department (ED) staff were exclusively replaced by broad‐spectrum strips. Causative chemical, time from triage to ophthalmology consultation, examination findings, ocular pH by ED and ophthalmology staff, and irrigation quantity were analyzed. Results: Most burns were alkaline. Time from triage (p = 0.043) and irrigation quantity following consultation (p = 0.047) each decreased following exclusive ED implementation of broad‐spectrum pH strips. There was greater pH congruence between consulting and primary physicians after intervention (p = 0.03). Conclusions: Exclusive non‐obstetric implementation of broad‐spectrum pH strips may allow greater accuracy and faster management of ocular chemical burns. Availability of narrow‐spectrum pH strips may be dangerous clinically by falsely reassuring the examiner with inherent inaccuracy. [ABSTRACT FROM AUTHOR]

The article discusses the acute coronary syndrome as the leading cause of worldwide mortality and morbidity. It examines interrater reliability of the HEART score which may affect management and low risk. It also examines hypothesis was that the HEART score is reliable for identifying low-risk in the patients.

Objectives: The pulmonary embolism rule-out criteria (PERC rule) is a nine-component decision rule derived to exclude pulmonary embolism (PE) without the use of formal diagnostic testing (D-dimer, computed tomography pulmonary angiography, ventilation–perfusion lung scanning, or venous ultrasonography) when all nine components are negative (“PERC negative”). This study examined whether clinicians who document PERC negative also document results of all nine components of the PERC rule. Methods: This was a pilot study at a single-center, urban teaching emergency department (ED) with a residency program in emergency medicine. Patients were over 17 years of age with at least one of nine predefined chief complaints. Clinicians were asked three questions regarding suspicion for PE, intent to use the PERC rule, and the result. Charts were independently reviewed by two authors for fidelity of the nine PERC components. Patients were followed for PE outcome at 14 days. Results: The study examined 526 patients cared for by 82 clinicians, who indicated suspicion for PE in 183 of 526 (35%) and intent to use the PERC rule in 115 of 526 (22%) cases, of whom 65 of 115 were documented as PERC negative. No formal test for PE was ordered in 49 of 65 (75%), and 46 of 49 had incomplete documentation to support PERC negative. The most common deficiency was omission of two risk factors for PE in the rule (prior venous thromboembolism or recent surgery). Six patients had PE diagnosed within 14 days, but none of these had been deemed PERC negative. Conclusions: Clinicians seldom document all nine data elements of the PERC rule in patients they deem PERC negative. These data suggest the need for paper or electronic aids to support use of the PERC rule. ACADEMIC EMERGENCY MEDICINE 2010; 17:1016–1019 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Background: The diagnostic strategy for pulmonary embolism (PE) includes a D‐dimer test when PE probability is low or intermediate, but false‐positive D‐dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule‐out criteria (PERC) rule excludes PE without D‐dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. Methods: This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC‐negative (PERC‐N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC‐N versus PERC‐positive (PERC‐P) patients at 3 months. Results: From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC‐N with a failure rate of 0.7% (95% confidence interval 0.6%–0.8%). PERC‐N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC‐N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3‐month follow‐up. Conclusions: A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE. [ABSTRACT FROM AUTHOR]

Background: Pulmonary embolism (PE) is a frequent diagnostic consideration in emergency department (ED) patients, yet diagnosis is challenging because symptoms of PE are nonspecific. Guidelines recommend the use of clinical decision tools to increase efficiency and avoid harms from overtesting, including D‐dimer screening in patients not at high risk for PE. Women undergo testing for PE more often than men yet have a lower yield from testing. Our study objective was to determine whether patient sex influenced the odds of received guideline‐consistent care. Methods: We performed a retrospective cohort study at two large U.S. academic EDs from January 1, 2016, to December 31, 2018. Nonpregnant patients aged 18–49 years were included if they presented with chest pain, shortness of breath, hemoptysis, or syncope and underwent testing for PE with D‐dimer or imaging. Demographic and clinical data were exported from the electronic medical record (EMR). Pretest risk scores were calculated using manually abstracted EMR data. Diagnostic testing was then compared with recommended testing based on pretest risk. The primary outcome was receipt of guideline‐consistent care, which required an elevated screening D‐dimer prior to imaging in all non–high‐risk patients. Results: We studied 1991 discrete patient encounters; 37% (735) of patients were male and 63% (1256) were female. Baseline characteristics, including revised Geneva scores, were similar between sexes. Female patients were more likely to receive guideline‐consistent care (70% [874/1256] female vs. 63% [463/735] male, p < 0.01) and less likely to be diagnosed with PE (3.1% [39/1256] female vs. 5.3% [39/735] male, p < 0.05). The most common guideline deviation in both sexes was obtaining imaging without a screening D‐dimer in a non–high‐risk patient (75% [287/382] female vs. 75% [205/272] male). Conclusions: In this cohort, females were more likely than males to receive care consistent with current guidelines and less likely to be diagnosed with PE. [ABSTRACT FROM AUTHOR]

Objective: The Pulmonary Embolism Quality‐of‐Life (PEmb‐QoL) questionnaire assesses quality of life (QoL) after pulmonary embolism (PE). We aimed to determine whether any clinical or pathophysiologic features of PE were associated with worse PEmb‐QoL scores 1 month after PE. Methods: In this prospective multicenter registry, we conducted PEmb‐QoL questionnaires. We determined differences in QoL domain scores for four primary variables: clinical deterioration (death, cardiac arrest, respiratory failure, hypotension requiring fluid bolus, catecholamine support, or new dysrhythmia), right ventricular dysfunction (RVD), PE risk stratification, and subsequent rehospitalization. For overall QoL score, we fit a multivariable regression model that included these four primary variables as independent variables. Results: Of 788 PE patients participating in QoL assessments, 156 (19.8%) had a clinical deterioration event, 236 (30.7%) had RVD of which 38 (16.1%) had escalated interventions. For those without and with clinical deterioration, social limitations had mean (±SD) scores of 2.07 (±1.27) and 2.36 (±1.47), respectively (p = 0.027). For intensity of complaints, mean (±SD) scores for patients without RVD (4.32 ± 2.69) were significantly higher than for those with RVD with or without reperfusion interventions (3.82 ± 1.81 and 3.83 ± 2.11, respectively; p = 0.043). There were no domain score differences between PE risk stratification groups. All domain scores were worse for patients with rehospitalization versus without. By multivariable analysis, worse total PEmb‐QoL scores with effect sizes were subsequent rehospitalization 11.29 (6.68–15.89), chronic obstructive pulmonary disease (COPD) 8.17 (3.91–12.43), and longer index hospital length of stay 0.06 (0.03–0.08). Conclusions: Acute clinical deterioration, RVD, and PE severity were not predictors of QoL at 1 month post‐PE. Independent predictors of worsened QoL were rehospitalization, COPD, and index hospital length of stay. [ABSTRACT FROM AUTHOR]

Background: For emergency physicians (EPs), acute vertigo is a challenging complaint and learning a reliable clinical approach is needed. STANDING is a four‐step bedside algorithm that requires (1) identifying spontaneous nystagmus with Frenzel glasses or, alternatively, a positional nystagmus; (2) characterizing the nystagmus direction; (3) assessing the vestibuloocular reflex (head impulse test); and (4) assessing the gait. The objective was to determine its accuracy for diagnosing central vertigo when using by naïve examiners as such as interns and its agreement with senior EPs. Methods: This was a prospective 1‐year diagnostic cohort study among patients with vertigo, vestibulovisual symptoms, or postural symptoms seen by 20 interns trained in the four‐step examination. The algorithm was performed first by an intern and second by a senior EP and categorized as either worrisome when indicating a central diagnosis and benign or inconclusive when indicating a peripheral diagnosis. The reference test was diffusion‐weighted brain magnetic resonance imaging. Results: Among 312 patients included, 57 had a central diagnosis including 33 ischemic strokes (10.5%). The main etiology was benign paroxysmal positional vertigo (32.7%). The likelihood ratios were 4.63 and 10.33 for a worrisome STANDING, 0.09 and 0.01 for a benign STANDING, and 0.21 and 0.35 for an inconclusive STANDING, for interns and senior EPs, respectively. The algorithm showed sensitivities of 84.8% (95% CI 75.6%–93.9%) and 89.8% (95% CI 82.1%–97.5%), negative predictive values of 96.2% (95% CI 93.7%–98.6%) and 97.5% (95% CI 95.5%–99.5%), specificities of 88.9% (95% CI 85.1%–92.8%) and 91.3% (95% CI 87.8%–94.8%), and positive predictive values of 64.1% (95% CI 53.5%–74.8%) and 70.7% (95% CI 60.4%–81.0%), respectively. The agreement between interns and senior EPs was very substantial (B‐statistic coefficient: 0.77) and almost perfect for each step: (1) 0.87, (2) 0.98, (3) 0.95, and (4) 0.99. Conclusions: With a single training session, the algorithm reached high accuracy and reliability for ruling out central causes of vertigo in the hands of both novices and experienced EPs. A future multicenter randomized controlled trial should further its impact on unnecessary neuroimaging use and patient's satisfaction. [ABSTRACT FROM AUTHOR]

Background: Suicide is a leading cause of death in the United States, particularly among Veterans. Nonfatal firearm injuries may indicate subsequent risk of suicide and, thus, provide important opportunities for prevention in emergency departments and other health care settings. We used a retrospective cohort design to analyze associations between nonfatal firearm injuries and subsequent suicide among all Veterans who used U.S. Department of Veterans Affairs (VA) health care, nationally, between 2010 and 2019. Methods: We linked VA health care and mortality data to identify VA users, nonfatal firearm injuries, and deaths. International Classification of Diseases (ICD)–10th Revision cause‐of‐death codes were used to identify suicides. Veterans' firearm injuries and their intent were categorized using cause‐of‐injury codes from the ICD Clinical Modification–9th and 10th Revisions systems. Using bivariable and multivariable regression, we estimated risk of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries. Among Veterans with nonfatal firearm injuries, we examined characteristics associated with subsequent suicide; electronic health record (chart) reviews explored documentation about firearm access among those who died. Results: Among 9,817,020 VA‐using Veterans, 11,503 experienced nonfatal firearm injuries (64.9% unintentional, 12.3% intentional self‐harm, 18.5% assault). Of these, 69 (0.6%) subsequently died by suicide (42 involving firearms). The odds of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries were 2.4 (95% confidence interval 1.9–3.0); odds were only slightly attenuated in multivariable modeling. Among Veterans with nonfatal firearm injuries, those with depression or substance use disorder diagnoses had twice the odds of subsequent suicide than those without. Chart reviews identified small proportions of suicide decedents who were assessed for (21.7%), and/or counseled about (15.9%), firearm access. Conclusions: Findings suggest that Veterans' nonfatal firearm injuries, regardless of injury intent, may be important but underutilized opportunities for suicide prevention. Future work should explore mechanisms to reduce risk among these patients. [ABSTRACT FROM AUTHOR]

Objectives: Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co‐ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. Methods: This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. Results: We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p = 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p = 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p = 0.038). Conclusions: When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury. [ABSTRACT FROM AUTHOR]

Background: Hemoptysis is not common in pulmonary embolism (PE) and lacks specificity for its diagnosis. However, this item is present in different validated scores that estimate the clinical probability of PE. The relevance of this item in clinical decision rules (CDRs) is not clearly established. Objective: The aim of this study was to evaluate the impact of removing the "hemoptysis" item from the PERC, YEARS, and PEGeD CDR in patients with low clinical probability of PE. Design: This was a post hoc analysis of two European prospective cohorts, which included 2968 patients presenting to the ED with a low clinical probability of PE (PROPER and PERCEPIC) and a 3‐month follow‐up. The primary endpoint was the false‐negative rate of a CDR score without the hemoptysis item. Secondary endpoints included the potential reduction of chest imaging if the item hemoptysis was to be removed and risk stratification of the Geneva and Wells scores without the hemoptysis item. Results: Of 2968 patients included (mean ± SD age 46 ± 18 years, 53% female), 87 patients (3%) had a PE diagnosed at 3 months. A total of 2908 were followed‐up at 3 months and analyzed. Using the PERC rule with and without the hemoptysis item, there were 13 and 14 missed cases of PE, respectively (failure rate 0.45% [95% CI 0.25%–0.78%] and 0.48% [95% CI 0.27%–0.82%]). Using the YEARS strategy, there were 11 missed PE cases with or without the hemoptysis item (false‐negative rate 0.57% [95% CI 0.30%–1.05%]). With the PERC and YEARS rule, removing the hemoptysis item would have led to a 1% reduction in chest imaging. The PEGeD strategy was not modified by the removal of the hemoptysis item. Conclusions: The hemoptysis item could be safely removed from the PERC, YEARS, and PEGeD CDRs. However, there was no subsequent clinically relevant reduction of chest imaging. [ABSTRACT FROM AUTHOR]

Background: Long‐term follow‐up for clinician–scientist training programs is sparse. We describe the outcomes of clinician–scientist scholars in the National Heart Lung and Blood Institute (NHLBI) K12 program in emergency care research up to 8.7 years after matriculation in the program. Methods: This was a cohort study of faculty clinician–scientist scholars enrolled in a NHLBI K12 research training program at 6 sites across the US, with median follow‐up 7.7 years (range 5.7–8.7 years) from the date of matriculation. Scholars completed electronic surveys in 2017 and 2019, with the 2019 survey collecting information for their current work setting, percent time for research, and grant funding from all sources. We used NIH RePorter and online resources to verify federal grants through March 2021. The primary outcome was a funded career development award (CDA) or research project grant (RPG) where the scholar was principal investigator. We included funding from all federal sources and national foundations. Results: There were 43 scholars, including 16 (37%) women. Over the follow‐up period, 32 (74%) received an individual CDA or RPG, with a median of 36 months (range 9–83 months) after entering the program. Of the 43 scholars, 23 (54%) received a CDA and 22 (51%) received an RPG, 7 (16%) of which were R01s. Of the 23 scholars who received a CDA, 13 (56%) subsequently had an RPG funded. Time to CDA or RPG did not differ by sex (women vs. men log‐rank test p = 0.27) or specialty training (emergency medicine versus other specialties, p = 0.59). Conclusions: After 7 years of follow‐up for this NHLBI K12 emergency care research training program, three quarters of clinician–scientist scholars had obtained CDA or RPG funding, with no notable differences by sex or clinical training. [ABSTRACT FROM AUTHOR]

Objectives: We sought to determine associations of early electrocardiogram (ECG) patterns with clinical deterioration (CD) within 5 days and with RV abnormality (abnlRV) by echocardiography in pulmonary embolism (PE). Methods: In this prospective, multicenter study of newly confirmed PE patients, early echocardiography and initial ECG were examined. Initial ECG patterns included lead‐specific ST‐segment elevation (STE) or depression (STD), T‐wave inversion (TWI), supraventricular tachycardia (SVT), sinus tachycardia, and right bundle branch block as complete (cRBBB) or incomplete (iRBBB). We defined CD as respiratory failure, hypotension, dysrhythmia, cardiac arrest, escalated PE intervention, or death within 5 days. We calculated odds ratios (ORs) for CD and abnlRV with univariate and full multivariate models in the presence of other variables. Results: Of 1676 patients, 1629 (97.2%) had both ECG and GDE; 415/1676 (24.7%) had CD, and 529/1629 (32.4%) had abnlRV. AbnlRV had an OR for CD of 4.25 (3.35, 5.38). By univariable analysis, the absence of abnormal ECG patterns had OR for CD and abnlRV of 0.34 (0.26, 0.44; p < 0.001) and 0.24 (0.18, 0.31; p < 0.001), respectively. By multivariable analyses, one ECG pattern had a significant OR for CD: SVT 2.87 (1.66, 5.00). Significant ORS for abnlRV were: TWI V2–4 4.0 (2.64, 6.12), iRBBB 2.63 (1.59, 4.38), STE aVR 2.42 (1.58, 3.74), S1‐Q3‐T3 2.42 (1.70, 3.47), and sinus tachycardia 1.68 (1.14, 2.49). Conclusions: SVT was an independent predictor of CD. TWI V2–4, iRBBB, STE aVR, sinus tachycardia, and S1‐Q3‐T3 were independent predictors of abnlRV. Finding one or more of these ECG patterns may increase considerations for performance of echocardiography to look for RV abnormalities and, if present, inform concerns for early clinical deterioration. [ABSTRACT FROM AUTHOR]

The article focuses on an observational cohort study which analyzes the relationship between blood product proportions in older adult trauma patients receiving major transfusions and mortality. The study concluded that the ratio of packed red blood cell (PRBCs) and fresh frozen plasma (FFP) was associated with significantly lower mortality than other transfusion ratios.

Objectives: Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5‐day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other. Methods: We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE. Results: Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77–0.82) and 0.71 (0.68–0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5‐day clinical deterioration by the multivariable logistic regression. Conclusions: A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5‐day clinical deterioration versus one without. [ABSTRACT FROM AUTHOR]

Objectives: Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk‐based STI screening program in our ED was associated with an increase in STI testing among at‐risk adolescents. Methods: We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio‐enhanced Computer‐Assisted Self‐Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing recommendations. Patient answers and testing recommendations were integrated in real‐time into the electronic health record. Patients who tested positive received treatment according to our standard‐of‐care practices. All patients 15–21 years of age were asked to complete this on an opt‐out basis, regardless of the reason for their ED visit. Exclusions included those unable to independently use a tablet, severe illness, sexual assault, or non‐English speaking. Our primary outcome was to describe STI‐testing recommendations and test results among ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not use it. Results: In the first 13 months, 28.9% (1788/6194) of eligible adolescents completed the ACASI and 44.2% (321/790) accepted recommended STI testing. The mean age of participants was 16.6 ± 1.3 years, with 65.4% (1169) being female. Gonorrhea/chlamydia testing was significantly higher among participants vs. non‐participants (20.1% [359/1788] vs 4.8% [212/4406]; p < 0.0001). The proportion of positive STI tests was similar between the two groups: 24.8% (89/359) vs. 24.5% (52/212; p = 0.94) were positive for chlamydia and/or gonorrhea, while 0.6% (2/354) participants vs. 0% non‐participants (p > 0.99) were positive for HIV. Among participants whose chief complaints were unlikely to be related to STIs but accepted recommended testing, 20.9% (37/177) were positive for gonorrhea or chlamydia. Conclusions: Our program facilitated STI testing in the ED and identified many adolescents with STIs, even when their ED complaint was for unrelated reasons. More rigorous implementation is needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations. [ABSTRACT FROM AUTHOR]

Objective: To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI). Methods: Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS. Results: In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model. Conclusion: The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition. [ABSTRACT FROM AUTHOR]

Objectives: Although the passage of blood in stools in children represents a medical emergency, children seeking emergency department (ED) care remain poorly characterized. Our primary objective was to compare clinical characteristics and etiologic pathogens in children with acute diarrhea with and without caregiver‐reported hematochezia. Secondary objectives were to characterize interventions and resource utilization. Methods: We conducted a secondary analysis of the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) database. Children <18 years presenting to two pediatric EDs within a 24‐hour period and <7 days of symptoms were consecutively recruited. Results: Of 1,061 participants, 115 (10.8%) reported hematochezia at the enrollment visit at which time those with hematochezia, compared to those without, had more diarrheal episodes/24‐hour period (9 vs. 6; difference: 2; 95% confidence interval [CI]: 2.0, 4.0; p < 0.001), and were less likely to have experienced vomiting (54.8% vs. 80.2%; difference: −25.4; 95% CI: −34.9, −16.0; p < 0.001). They were more likely to receive intravenous fluids (33.0% vs. 17.9%; difference: 15.2; 95% CI: 6.2, 24.1; p < 0.001) and require repeat health care visits (45.5% vs. 34.7%; difference: 10.7; 95% CI: 0.9, 20.6; p = 0.03). A bacterial pathogen was identified in 33.0% of children with hematochezia versus 7.9% without (difference: 25.1; 95% CI: 16.3, 33.9; p < 0.001); viruses were detected in 31.3% of children with hematochezia compared to 72.3% in those without (difference: −41.0%, 95% CI: −49.9, −32.1; p < 0.001). Conclusion: In children with acute diarrhea, caregiver report of hematochezia, compared to the absence of hematochezia, was associated with more diarrheal but fewer vomiting episodes, and greater resource consumption. The former group of children was also more likely to have bacteria detected in their stool. [ABSTRACT FROM AUTHOR]

Objectives: Appendicitis is a common pediatric condition requiring surgery. The pediatric appendicitis risk calculator (pARC) was recently developed to guide clinical care. The objective of this study is to describe resource utilization and clinical outcomes among children with appendix ultrasound (US) scans risk stratified by pARC score. Methods: Prospective enrolled observational cohort single‐center study of children aged 5–18, who had an US for suspected appendicitis. We estimated the rate of appendicitis, rate of equivocal US scans, and resource utilization by pARC score strata. Total adjusted charges were determined for low‐risk pARC patients compared to discharged emergency department (ED) patients with abdominal pain and complete blood count (CBC) obtained without advanced abdominal imaging. Results: Over the 13‐month study period, 407 children were enrolled. The overall rate of appendicitis was 33.4%, and 199 (49%) were male. The observed rate of appendicitis was 3.3% in those with a pARC score of <15% and 96.8% in those with a pARC score of ≥85%. Of enrolled patients, 152 (37.3%) had a pARC score <15%. Of those with a pARC score of <15%, the negative appendectomy rate was 28.6%, and the rate of equivocal US was 49.3%. The rate of CT scans and hospitalizations was 19% and 23%, respectively. Median total charges for patients with pARC <15% with usual care were $3756. Median total charges for patients presenting to the ED with abdominal pain who had a CBC but no advanced abdominal imaging performed was $2484, indicating a potential savings of $1272 per patient. Conclusions: There is a high rate of resource utilization among patients who are low appendicitis risk by pARC score. Outcome variation by pARC scores presents future opportunity to selectively reduce resource utilization in pediatric patients. [ABSTRACT FROM AUTHOR]

Study Objective: Emergency department (ED)‐based naloxone distribution and peer‐based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation. Methods: We conducted a retrospective cohort study of an ED overdose prevention program providing take‐home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression. Results: Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take‐home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take‐home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time. Conclusions: ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low‐cost implementation strategies to improve services use and dissemination across clinical settings. [ABSTRACT FROM AUTHOR]

Objectives: Urinary neutrophil gelatinase‐associated lipocalin (uNGAL) appears highly accurate to identify urinary tract infections (UTIs) when obtained via catheterization. Our primary aim was to determine the agreement in uNGAL levels between paired catheter and bag urine specimens. Our secondary aim was to compare the diagnostic test characteristics of quantitative uNGAL, dipstick uNGAL (a potential point‐of‐care test), and urinalysis (UA). Methods: This was a prospective study of febrile children < 24 months evaluated for UTIs. We evaluated quantitative uNGAL at a previously identified threshold of 39.1 ng/mL, dipstick uNGAL at its built‐in threshold of >50 ng/mL, and UA at standard thresholds for leukocyte esterase (LE). A positive urine culture was defined as >100,000 CFUs/mL of a pathogen. Results: A total of 211 patients were included (10% with positive urine cultures); 116 had paired catheterized and bagged samples. The agreement between catheterized and bagged samples at a quantitative uNGAL cutoff of ≥39.1 ng/mL was 0.76 (95% confidence interval [CI] = 0.67 to 0.83) and 0.77 (95% CI = 0.68 to 0.84) at a uNGAL dipstick threshold of >50 ng/mL. The area under the receiver operating characteristic curve for uNGAL from a catheterized sample was 0.96 (95% CI = 0.89 to 1.00) compared to 0.93 (95% CI = 0.87 to –0.99) from a bagged sample. The sensitivities of catheterized sample quantitative and dipstick uNGAL (90.5%) were higher than UA at a LE threshold of ≥1+ (57.1%). Bagged‐sample uNGAL had lower quantitative and dipstick specificities (both 73.8%) than from catheterized samples (94.3% and 95.3% respectively), similar to UA. Conclusions: uNGAL from bagged and catheterized samples showed insufficient agreement to be used interchangeably. The low specificity of uNGAL from bagged samples suggests that sampling technique affects uNGAL levels. [ABSTRACT FROM AUTHOR]

Purpose: Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. Methods: We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. Results: Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6–19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. Conclusion: In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change. [ABSTRACT FROM AUTHOR]

Objective: The objective was to evaluate the efficacy and safety of single‐dose ketamine infusion in adults with sickle cell disease (SCD) who presented with acute sickle vasoocclusive crisis (VOC). Methods: This study was a parallel‐group, prospective, randomized, double‐blind, pragmatic trial. Participants were randomized to receive a single dose of either ketamine or morphine, infused over 30 min. Primary outcome was mean difference in the numerical pain rating scale (NPRS) score over 2 h. NPRS was recorded every 30 min for a maximum of 180 min and secondary outcomes were cumulative dose of opioids, emergency department (ED) length of stay, hospital admission, change in vital signs, and drug‐related side effects. Authors performed the analysis using intention‐to‐treat principle. Result: A total of 278 adults with SCD and who presented with acute sickle VOC participated in this trial. A total of 138 were allocated to the ketamine group. Mean (±standard deviation [SD]) NPRS scores over 2 h were 5.7 (±2.13) and 5.6 (±1.90) in the ketamine and morphine groups. The ketamine group received significantly lower cumulative doses of morphine during their ED stay (mean ± SD = 4.5 ± 4.6 mg) than of the morphine group (mean ± SD = 8.5 ± 7.55 mg). Both groups had similar rates of hospital admission: 6.3% in the ketamine group had drug‐related side effects compared to 2.2% in the morphine group. Conclusion: Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2‐h period and reduced the cumulative morphine dose in the ED with no significant drug‐related side effects in the ketamine‐treated group. [ABSTRACT FROM AUTHOR]

Objective: The main objective of this study was to evaluate the accuracy of point‐of‐care ultrasound (POCUS) for the diagnosis of appendicitis in a general emergency department (ED) population as performed by emergency physicians with variable ultrasound experience. Methods: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential appendicitis presenting to the ED between July 2014 and February 2020. Each emergency physician–performed POCUS was interpreted at the bedside and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS and blinded expert interpretation compared to surgical pathology in patients undergoing appendectomy and advanced imaging in patients managed nonoperatively. Results: A total of 256 subjects were included in the primary analysis with an overall appendicitis prevalence of 28.1%. For the diagnosis of appendicitis, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.85 (95% confidence interval [CI] = 0.74 to 0.92), 0.63 (95% CI = 0.56 to 0.70), 2.29 (95% CI = 1.85 to 2.84), and 0.24 (95% CI = 0.14 to 0.42), respectively. Expert review yielded a lower sensitivity (0.74 [95% CI = 0.62 to 0.83]) with a similar specificity (0.63 [95% CI = 0.56 to 0.70]). Conclusion: POCUS is moderately accurate for acute appendicitis as performed by emergency physicians with a wide range of ultrasound expertise, but lacks adequate sensitivity and specificity to function as a definitive test in an undifferentiated ED population. Further study is warranted to elucidate the optimal role of integrated POCUS in the general approach to suspected appendicitis. [ABSTRACT FROM AUTHOR]

The article discusses a study that compares the sensitivity of provider performed and self-obtained vaginal swabs in an emergency department setting and explores patient preference. Highlights include non-inferiority of self-obtained swabs for Neisseria gonorrhoeae and Chlamydia trachomatis, percentage of patients who felt that collecting a self-sample is acceptable, and percentage of patients who refused self-swabs due to reasons related to the collection procedure.

Background: Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history‐based score ABCD2. Methods: This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD2 ≥ 4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion‐weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination. Results: We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+] = 3.71, negative likelihood ratio [LR–] = 0.09) than the HINTS test (67% and 44%, respectively; LR+ = 2.96, LR– = 0.04). The ABCD2 score was specific (82%, LR+ = 3.04, LR– = 0.56) but had a very low PPV (44%). Conclusions: In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use. [ABSTRACT FROM AUTHOR]

The authors discuss a study that examines the diagnostic accuracy and interreader reliability of novice-acquired three-dimensional ultrasound (3DUS) point-of-care for evaluation of extracranial carotid artery stenosis. Highlights include the low cost and portability of 3DUS by two-dimensional augmentation, training of operators to acquire volumes spanning from skull base to base of the neck to improve field of view, and roll-and-yaw correction using existing sensor data.

Background: Back pain is often benign but can be a harbinger for serious pathology. Little is known about the outcome in children with back pain but no serious diagnoses detected at the initial visit. We sought to estimate the rate of serious diagnoses at revisits among children initially discharged from the emergency department (ED) with back pain. Methods: We performed a multicenter retrospective cohort study of patients from 45 pediatric hospitals in the Pediatric Health Information System database from October 1, 2015, to March 31, 2019. We included patients discharged from the ED with a principal diagnosis of back pain and excluded patients with trauma and concurrent or previously known serious diagnoses. We identified the rates and types of serious diagnoses made within 30 days of the index visit. We examined the rates of diagnostic tests at the index visit in patients with and without serious diagnoses. Results: Of the 25,130 patients with back pain, 88 (0.4%, 95% confidence interval = 0.3% to 0.4%) had serious pathology diagnosed within 30 days. The most common diagnoses were anatomic (40%) and nonneurologic (39%) categories such as vertebral fracture and nephrolithiasis; infectious (19%) and neoplastic etiologies (3%) were less common. Diagnoses requiring acute interventions such as cauda equina syndrome (n = 2) and intraspinal abscess (n = 3) were rare. Patients with serious diagnoses at revisits underwent more blood tests and back ultrasound at the index visit compared to patients without serious diagnoses. Conclusions: In pediatric patients discharged from the ED with a diagnosis of back pain and no serious or trauma diagnoses, there is a low rate of serious pathology on revisits. Of the serious diagnoses identified, high‐acuity diseases were rare. For the subset of patients with clinical suspicion for serious pathology but none identified at the index visit, this represents an opportunity for further research to optimize their management. [ABSTRACT FROM AUTHOR]

Objective: The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). Methods: This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active‐duty opioid‐naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow‐up measurement was from 31 to 365 days after the index encounter. The primary outcome was long‐term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow‐up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military‐duty restriction. Results: We found a 2.5‐fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180‐day opioid supply during follow‐up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. Conclusion: In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes. [ABSTRACT FROM AUTHOR]

Objective: This study seeks to evaluate the test characteristics of D‐dimer for pulmonary embolism (PE) in patients with a concurrent diagnosis of COVID‐19. We hypothesized that the sensitivity of D‐dimer for PE at current institutional cut points would be similar to those without COVID‐19. Methods: This is a multicenter retrospective observational cohort study across five urban and suburban EDs in the same health care system. The electronic health record was queried for all computed tomography pulmonary angiography (CTPA) studies from December 1, 2019, to October 22, 2020. All ED patients who underwent CTPA had D‐dimer and COVID‐19 testing completed in a single encounter were included in the study. Baseline demographics were obtained. Test characteristics of D‐dimer for PE were calculated for patients with and without COVID‐19. Additionally, receiver operator characteristics (ROC) curves were constructed for two different D‐dimer assays. Results: There were 1158 patient encounters that met criteria for analysis. Performance of D‐dimer testing for PE was similar between COVID‐19–positive and –negative patients. In COVID‐19–positive patients, the sensitivity was 100% (95% confidence interval [CI] = 87.6%–100%), specificity was 11.9% (95% CI = 7.9%–17.1%), and negative predictive value (NPV) was 100%. In COVID‐19–negative patients the sensitivity was 97.6% (95% CI = 91.5%–99.7%), specificity was 14.4% (95% CI = 12.1%–17%), and NPV was 98.3% (95% CI = 93.8%–99.6%). For assay 1 the area under the curve (AUC) for COVID‐19–positive patients was 0.76 (95% CI = 0.68–0.83), and for COVID‐19–negative patients, 0.73 (95% CI = 0.69–0.77). For assay 2, AUC for COVID‐19–positive patients was 0.85 (95% CI = 0.77–0.92), and for COVID‐19–negative patients, 0.80 (95% CI = 0.77–0.84). Inspection of the ROC curve for assay 1 revealed that 100% sensitivity was maintained up to a threshold of 0.67 FEU (fibrinogen equivalent units; from 0.50 FEU) with an increase in specificity to 29% (from 18.7%), and for assay 2, 100% sensitivity was maintained up to a threshold of 662 D‐dimer units (DDU; from 230 DDU) with an increased specificity to 59% (from 6.1%). Conclusion: Results from this multicenter retrospective study did not find a significant difference in sensitivity of D‐dimer for PE due to concomitant COVID‐19 infection. Further study is required to determine if PE can safely be excluded based on D‐dimer results alone in patients with suspected or proven COVID‐19 or if adjusted D‐dimer levels could have a role in management. [ABSTRACT FROM AUTHOR]

Background: Widespread vaccination is an essential component of the public health response to the COVID‐19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban emergency departments (EDs) and characterize underlying factors contributing to hesitancy. Methods: Adult ED patients with stable clinical status (Emergency Severity Index 3–5) and without active COVID‐19 disease or altered mental status were considered for participation. Demographic elements were collected as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in person via a survey instrument proctored by trained research assistants. Results: A total of 1,555 patients were approached, and 1,068 patients completed surveys (completion rate = 68.7%). Mean (±SD) age was 44.1 (±15.5) years (range = 18–93 years), 61% were female, and 70% were Black. A total of 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were health care workers. In multivariable regression analysis, Black race (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 2.62 to 6.85) and younger age (age 18–24 years—OR = 4.57, 95% CI = 2.66 to 7.86; age 25–35 years—OR = 5.71, 95% CI = 3.71 to 8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less—OR = 2.27, 95% CI = 1.23 to 4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than nonhesitant patients (39.6% vs. 78.9%, p < 0.001); less difference was noted in the domain of trust toward friends/family (51.1% vs. 61.0%, p = 0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research. Conclusions: Vaccine hesitancy is common among ED patients and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources but less so friends or family. This suggests that strategies to combat hesitancy may need tailoring to specific populations. [ABSTRACT FROM AUTHOR]

Background: Faculty diversity is a high‐priority goal for academic emergency medicine (EM). Most administrators currently monitor faculty diversity using aggregate data, which may obscure underrepresentation by rank. We apply the Rank Equity Index (REI) to EM faculty data to assess rank progression. Methods: We calculated the REI (% faculty cohort higher rank/% faculty cohort lower rank) for EM faculty. We performed REI analyses by faculty gender (women, men) and race/ethnicity (White, Black, Hispanic/Latinx, Asian). We compared professor/assistant professor, professor/associate professor, and associate professor/assistant professor to establish rank parity for gender and race/ethnicity. Parity is an REI of 1.0. Results: REI analysis by gender demonstrates that women faculty did not achieve parity at any rank comparison in any study year. REI analysis by race/ethnicity demonstrates that all faculty of color are below parity at the assistant to associate professor promotion. Latinx faculty are at parity for associate professor to professor, but Asian and Black faculty do not achieve parity in any comparison. Intersecting gender and race/ethnicity in the REI analysis demonstrates that Asian women have the lowest REIs among all faculty ranks and races/ethnicities. Men of all races/ethnicities achieved parity in two of three rank comparisons, except for Black men, who did not achieve parity in any comparison. Conclusions: REI analysis demonstrates EM women faculty and faculty of color are not achieving rank parity and are disadvantaged at the first tier of promotion. A preliminary longitudinal trend analysis suggests little progress. Asian women and Black men experience the most rank inequity. REI analysis identifies a need for focused faculty development to enhance our most vulnerable faculty's rank progression, suggesting that targeted recruitment and retention efforts of women faculty of all races/ethnicities and faculty of color, in particular, will improve diversity at every tier of faculty rank. [ABSTRACT FROM AUTHOR]

Objective: Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury. Methods: This was a retrospective cohort study of children 0 to 18 years with ICD‐9/ICD‐10 diagnosis codes for firearm injury (excluding nonpowder) in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included: (1) difference in health care encounters for 1 year before and 1 year after injury, (2) difference in health care expenditures, and (3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed‐rank tests. Results: Among 1,821 children, there were 22,398 health care encounters before the injury and 28,069 after. Concomitantly, there was an overall increase of $16.5 million in health expenditures ($9,084 per patient). There was a 50% increase in children qualifying for complex chronic condition status after firearm injury. Conclusions: Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs. [ABSTRACT FROM AUTHOR]

Objectives: Accurate estimation of the risk of SARS‐CoV‐2 infection based on bedside data alone has importance to emergency department (ED) operations and throughput. The 13‐item CORC (COVID [or coronavirus] Rule‐out Criteria) rule had good overall diagnostic accuracy in retrospective derivation and validation. The objective of this study was to prospectively test the inter‐rater reliability and diagnostic accuracy of the CORC score and rule (score ≤ 0 negative, > 0 positive) and compare the CORC rule performance with physician gestalt. Methods: This noninterventional study was conducted at an urban academic ED from February 2021 to March 2021. Two practitioners were approached by research coordinators and asked to independently complete a form capturing the CORC criteria for their shared patient and their gestalt binary prediction of the SARS‐CoV‐2 test result and confidence (0%–100%). The criterion standard for SARS‐CoV‐2 was from reverse transcriptase polymerase chain reaction performed on a nasopharyngeal swab. The primary analysis was from weighted Cohen's kappa and likelihood ratios (LRs). Results: For 928 patients, agreement between observers was good for the total CORC score, κ = 0.613 (95% confidence interval [CI] = 0.579–0.646), and for the CORC rule, κ = 0.644 (95% CI = 0.591–0.697). The agreement for clinician gestalt binary determination of SARs‐CoV‐2 status was κ = 0.534 (95% CI = 0.437–0.632) with median confidence of 76% (first–third quartile = 66–88.5). For 425 patients who had the criterion standard, a negative CORC rule (both observers scored CORC < 0), the sensitivity was 88%, and specificity was 51%, with a negative LR (LR−) of 0.24 (95% CI = 0.10–0.50). Among patients with a mean CORC score of >4, the prevalence of a positive SARS‐CoV‐2 test was 58% (95% CI = 28%–85%) and positive LR was 13.1 (95% CI = 4.5–37.2). Clinician gestalt demonstrated a sensitivity of 51% and specificity of 86% with a LR− of 0.57 (95% CI = 0.39–0.74). Conclusion: In this prospective study, the CORC score and rule demonstrated good inter‐rater reliability and reproducible diagnostic accuracy for estimating the pretest probability of SARs‐CoV‐2 infection. [ABSTRACT FROM AUTHOR]

Background: Screening for malaria in the returning traveler has often required repeat testing; however, audit data suggest that patients have not been reattending. We sought to ascertain if this was safe by examining the diagnostic efficacy of a single screen consisting of a rapid diagnostic test (RDT) and a thin film. Methods: We conducted a retrospective cohort study of patients with suspected malaria who attended in the past 5 years from two large teaching hospitals. We assessed the diagnostic accuracy of a single screen, reporting measures of sensitivity and specificity. To establish a reference standard, we cross‐linked data with the national malaria registry held at Public Health England and regional centers. Results: The cohort consisted of 1365 patients, of whom 33 opted out of the research and one did not have a complete initial screen. Of those 1331 screens there were 74 cases of Plasmodium falciparum (prevalence of 5.6%) and 104 of any malaria species (prevalence of 7.8%). Sensitivity for the detection of P. falciparum was 100.00% (95% confidence interval [CI] = 95.1 to 100), with a specificity of 99.4% (95% CI = 98.9 to 99.8). For the detection of any species of malaria the sensitivity was slightly lower due to the presence of one false negative; sensitivity was 99.0% (95% CI = 94.8 to 100) and specificity was 99.5% (95% CI = 98.9 to 99.8). Conclusions: A single thin film and RDT is likely to be sufficient as a first screen for falciparum malaria in the returning traveler with important caveats. For those sent home from emergency departments, appropriate safety netting must be provided. Further prospective study is required to investigate this approach. [ABSTRACT FROM AUTHOR]

Objective: Provider‐performed endocervical sampling (PPES) in the diagnosis of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) may be difficult to perform in a busy emergency department (ED) due to patient preference, availability of the pelvic examination room, or provider availability. Our objective was to assess if self‐obtained vaginal swabs (SOVS) were noninferior to PPES in the ED diagnosis of NG/CT using a rapid nucleic acid amplification test (NAAT). Methods: We conducted a prospective observational cohort study in a single ED. Participants were adult female English‐ and Spanish‐speaking patients in whom the ED provider felt that NG/CT testing was warranted. Each patient had SOVS and PPES performed. For SOVS, a research associate reviewed a one‐page handout describing the procedure but gave no other assistance. Patients answered survey questions regarding acceptability of SOVS and symptomatology. We established a minimum sensitivity of 90% for SOVS to be considered clinically noninferior to standard PPES. Results: A total of 533 patients completed enrollment and answered survey questions, 515 of whom had laboratory results for both SOVS and PPES. There were 86 patients with a positive result: 29 with NG, 47 with CT, and 10 with coinfection. SOVS had a sensitivity of 95% (95% confidence interval = 88% to 99%) for the detection of NG/CT when compared to PPES. SOVS were felt to be an acceptable collection method in 93% of patients and 75% preferred SOVS to PPES. Conclusion: SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to determine if 0.15 mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3 mg/kg in emergency department (ED) patients with acute pain. Methods: This randomized, prospective, double‐blinded, noninferiority trial included patients' age 18 to 59 years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15 mg/kg ("low" dose) or 0.30 mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11‐point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ0, was set to 1.3. Results: Forty‐nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low‐dose group and 5.0 (95% CI = 4.2 to 5.8) in the high‐dose group (mean difference = 0.4, 95% CI = −0.8 to 1.5), indicating that the low‐dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI = –0.8 to ≥1.3 = –δ0). Adverse effects were similar at 30 minutes. At 15 minutes, the high‐dose group experienced greater change in NRS; however, more adverse effects occurred. Conclusion: Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.30 mg/kg in the short‐term treatment of acute pain in the ED. [ABSTRACT FROM AUTHOR]

Background: Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. However, a CT exposes patients to 100 times more radiation than a chest radiograph. Previously, we developed a four‐item clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) do not require emergent neuroimaging. In this study, we seek to prospectively validate our CDI in patients with a history of seizures with both SE and generalized tonic–clonic seizures. Methods: This was a prospective observational study of 1,739 consecutive patients who were recruited from two urban hospitals in Philadelphia, Pennsylvania. All patients, 18 years and older, who presented with a chief complaint of seizure and had emergency neuroimaging performed were eligible for inclusion. Patients were excluded from analysis if this was a first‐time seizure, had a ventriculoperitoneal shunt, or had focal neurologic deficits. Results: A total of 376 patients were in the final analysis. Of the 376 patients, 10 patients (3%) had positive CTs. Nine of the 10 of the patients were identified by our CDI, resulting in a negative predictive value (NPV) of 99.5%. On secondary analysis, we refined our CDI from four to three criteria: 1) history of intracranial hemorrhage (ICH), 2) active malignancy, and 3) trauma. These criteria also had a NPV of >99% when applied to patients in SE. Conclusion: The validation of our CDI showed improved NPV when compared to the derivation set. Use of the criteria of history of ICH, active malignancy, and trauma could have reduced the use of emergent neuroimaging in our cohort by up to 49%. This CDI should be validated in a larger subset of patients and in multiple centers prior to widespread adoption. [ABSTRACT FROM AUTHOR]

Introduction: The HINTS exam is a series of bedside ocular motor tests designed to distinguish between central and peripheral causes of dizziness in patients with continuous dizziness, nystagmus, and gait unsteadiness. Previous studies, where the HINTS exam was performed by trained specialists, have shown excellent diagnostic accuracy. Our objective was to assess the diagnostic accuracy of the HINTS exam as performed by emergency physicians on patients presenting to the emergency department (ED) with a primary complaint of vertigo or dizziness. Methods: A retrospective cohort study was performed using data from patients who presented to a tertiary care ED between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient characteristics of those who received the HINTS exam were assessed along with sensitivity and specificity of the test to rule out a central cause of stroke. Results: A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix‐Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam. Conclusions: Our results suggest that despite widespread use of the HINTS exam in our ED, its diagnostic value in that setting was limited. The test was frequently used in patients who did not meet criteria to receive the HINTS exam (i.e., continuous vertigo, nystagmus, and unsteady gait). Additional training of emergency physicians may be required to improve test sensitivity and specificity. [ABSTRACT FROM AUTHOR]

Objectives: Physicians' gestalt is central in the diagnostic pipeline of suspected COVID‐19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID‐19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results. Methods: From April 1 to April 30, 2020, patients with suspected COVID‐19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID‐19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt [CG]) and after evaluation of clinical features and results of lung ultrasound or chest x‐ray (clinical and bedside imaging–integrated gestalt [CBIIG]). The final diagnosis was adjudicated after independent review of 30‐day follow‐up data. Results: Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID‐19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID‐19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT‐PCR had a sensitivity of 98.4% for COVID‐19 (p < 0.01 vs. RT‐PCR alone) compared to 95.9% for CG plus RT‐PCR (p = 0.05). Conclusions: In suspected COVID‐19, CG and CBIIG have fair diagnostic accuracy, in line with physicians' gestalt for other acute conditions. Negative RT‐PCR plus low probability based on CBIIG can rule out COVID‐19 with a relatively low number of false‐negative cases. [ABSTRACT FROM AUTHOR]

Objective: While guidelines recommend outpatient management of patients with low‐risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs. Methods: This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1, 2016, through June 30, 2018. The primary outcome was the initial disposition following an ED visit for acute PE. Additional measures included hospital cost and 30‐day revisit rate to the ED. Results: A total of 61,070 cases were included in the overall cohort, of which 4.1% of new cases of PE were discharged from the ED. The median hospital‐specific proportion of patients discharged was 3.1% (interquartile range = 0.8%–6.8%). The median odds ratio, representing the importance of the hospital in initial disposition decisions, was 2.21 (95% confidence interval = 2.05 to 2.37), which was greater than any patient‐level factor with the exception of concurrent ED diagnosis of hypoxemia/respiratory failure, shock, or hypotension. Within 30 days of discharge, 17.9% of discharged cases had an ED return visit to the ED only and 10.3% of patients were hospitalized. Of the 30‐day ED return visits in patients initially managed as outpatients, 1.3% had a bleeding‐associated diagnosis. Conclusion: Despite guidelines promoting outpatient management, few patients are currently discharged home in the United States; however, practice varies widely across hospitals. Return visit rates were high but most did not result in hospitalization. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to provide a longitudinal assessment of anxiety levels and work and home concerns of U.S. emergency physicians during the COVID‐19 pandemic. Methods: We performed a longitudinal, cross‐sectional email survey of clinically active emergency physicians (attending, fellow, and resident) at seven academic emergency departments. Follow‐up surveys were sent 4 to 6 weeks after the initial survey and assessed the following: COVID‐19 patient exposure, availability of COVID‐19 testing, levels of home and workplace anxiety/stress, changes in behaviors, and performance on a primary care posttraumatic stress disorder screen (PC‐PTSD‐5). Logistic regression explored factors associated with a high PC‐PTSD‐5 scale score (≥3), indicating increased risk for PTSD. Results: Of the 426 surveyed initial respondents, 262 (61.5%) completed the follow‐up survey. While 97.3% (255/262) reported treating suspected COVID‐19 patients, most physicians (162/262, 61.8%) had not received testing themselves. In follow‐up, respondents were most concerned about the relaxing of social distancing leading to a second wave (median score = 6, IQR = 4–7). Physicians reported a consistently high ability to order COVID‐19 tests for patients (median score = 6, IQR = 5–7) and access to personal protective equipment (median score = 6, IQR = 5–6). Women physicians were more likely to score ≥ 3 than men on the PC‐PTSD‐5 screener on the initial survey (43.3% vs. 22.5%; Δ 20.8%, 95% confidence interval [CI] = 9.3% to 31.5%), and despite decreases in overall proportions, this discrepancy remained in follow‐up (34.7% vs. 16.8%; Δ 17.9%, 95% CI = 7.1% to 28.1%). In examining the relationship between demographics, living situations, and institution location on having a PC‐PTSD‐5 score ≥ 3, only female sex was associated with a PC‐PTSD‐5 score ≥ 3 (adjusted odds ratio = 2.48, 95% CI = 1.28 to 4.79). Conclusions: While exposure to suspected COVID‐19 patients was nearly universal, stress levels in emergency physicians decreased with time. At both initial and follow‐up assessments, women were more likely to test positive on the PC‐PTSD‐5 screener compared to men. [ABSTRACT FROM AUTHOR]

The article discusses the increasing use of mental health visits in U.S. emergency departments (EDs) and the shortage of mental health providers. Topic include explores the impact of telemental health (TMH) services, conducted via video consultation, on post-visit utilization and processes of care among patients in Veterans Affairs (VA) ED and urgent care clinic.Also study uses a retrospective cohort design and analyzes outcomes related to return visits, hospitalizations, medication changes.

The article discusses assessment of a third neonatal lumbar puncture position by ultrasound measurement. It mentions study to investigate whether a diaper change approach may provide an additional option for performing neonatal LPs; and also mentions lateral decubitus and sitting positions had larger average interspinous distances.

Background: Despite reported higher rates and worse outcomes due to COVID‐19 in certain racial and ethnic groups, much remains unknown. We explored the association between Hispanic ethnicity and outcomes in COVID‐19 patients in Long Island, New York. Methods: We conducted a retrospective cohort study of 2,039 Hispanic and non‐Hispanic Caucasian patients testing positive for SARS‐CoV‐2 between March 7 and May 23, 2020, at a large suburban academic tertiary care hospital near New York City. We explored the association of ethnicity with need for intensive care unit (ICU), invasive mechanical ventilation (IMV), and mortality. Results: Of all patients, 1,079 (53%) were non‐Hispanic Caucasians and 960 (47%) were Hispanic. Hispanic patients presented in higher numbers than expected for our catchment area. Compared with Caucasians, Hispanics were younger (45 years vs. 59 years), had fewer comorbidities (66% with no comorbidities vs. 40%), were less likely to have commercial insurance (35% vs. 59%), or were less likely to come from a nursing home (2% vs. 10%). In univariate comparisons, Hispanics were less likely to be admitted (37% vs. 59%) or to die (3% vs. 10%). Age, shortness of breath, congestive heart failure (CHF), coronary artery disease (CAD), hypoxemia, and presentation from nursing homes were associated with admission. Male sex and hypoxemia were associated with ICU admission. Male sex, chronic obstructive pulmonary disease, and hypoxemia were associated with IMV. Male sex, CHF, CAD, and hypoxemia were associated with mortality. After other factors were adjusted for, Hispanics were less likely to be admitted (odds ratio = 0.62, 95% confidence interval = 0.52 to 0.92) but Hispanic ethnicity was not associated with ICU admission, IMV, or mortality. Conclusions: Hispanics presented at higher rates than average for our population but outcomes among Hispanic patients with COVID‐19 were similar to those of Caucasian patients. [ABSTRACT FROM AUTHOR]

Objectives: We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6‐month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED. Methods: This study is part of an ongoing longitudinal study of 754 community‐living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14‐year follow‐up period (1998–2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty‐nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model. Results: In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower‐extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors. Conclusions: Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower‐extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED. [ABSTRACT FROM AUTHOR]

Background: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri‐intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. Methods: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri‐intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. Results: There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri‐intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri‐intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri‐intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg. Conclusions: Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation. [ABSTRACT FROM AUTHOR]

Objectives: Opioids are commonly administered in the emergency department (ED) and prescribed for the treatment of back pain. It is important to understand the unintended consequences of this approach to inform treatment decisions and the consideration of alternative treatments. Recent evidence has shown that ED opioid prescriptions are associated with future opioid use. The objective of this study was to measure the association of opioid administration in the ED to patients treated for back pain with future opioid use. Methods: This is a retrospective study of opioid‐naïve adults discharged from the ED with a diagnosis of back pain. Patients were stratified by opioid therapy (none, ED administration only, prescription only, or ED administration + prescription). Relative risks of ongoing opioid use (filling >90‐day supply in 180 days following ED visit as documented in the prescription drug monitoring program) were calculated for each opioid‐therapy group and compared to the no‐opioid group. Results: We identified 24,487 opioid naïve back pain patients. The median age was 38 years, 55% were female, and 56% were non‐Hispanic white. A total of 41% received no opioid, 10% were only administered an opioid in the ED, 18% only received a prescription, and 31% received an opioid in the ED + prescription. The adjusted relative risks of ongoing use compared to the no opioid group were as follows: ED only 1.9, prescription only 2.1, and ED + prescription 2.3. The increased risk persisted for other definitions of ongoing use and after adjustment for baseline pain scores. Conclusions: For opioid‐naïve patients with back pain, both administration of an opioid in the ED and opioid prescriptions are associated with a doubling of the risk of ongoing opioid use compared to patients not treated with opioids. This supports the consideration of minimizing exposure to opioids while treating back pain in the ED. [ABSTRACT FROM AUTHOR]

Background: There is limited research on loop drainage (LD) compared to incision and drainage (I&D) for treatment of cutaneous abscesses. We investigated whether LD was noninferior to I&D for abscess resolution and whether there was any difference in repeat ED visits or complication rates between these techniques. Methods: We performed a prospective randomized controlled trial, using a convenience sample at an urban academic emergency department (ED). Subjects over 18 years who presented for first‐time management of an abscess were eligible. Patients requiring specialist drainage or hospital admission or had previous treatment for the abscess were excluded. Enrolled subjects were seen 2 weeks after treatment for blinded reevaluation of abscess resolution, and the electronic medical record was reviewed for return ED visits/abscess complications. Results: Of 2,889 patients screened, 238 subjects consented and were randomized to LD or I&D. Abscess resolution was achieved in 53/65 (81.5%) of patients in the I&D arm, compared to 66/75 (88%) in the LD arm. Fewer patients in the LD group compared to the I&D group returned to the ED for abscess‐related management during the following 14 days (37.3% vs 67.1%, p = 0.002). Among returning subjects, there was a significant difference in mean visits per subject between LD and I&D groups (0.5 vs. 1.2, p = 0.001). There were fewer complications among LD than I&D subjects (9.3% vs. 24.6%, p = 0.01). Conclusion: Our study provides evidence that LD is noninferior to I&D in achieving complete abscess resolution at 14 days and is associated with fewer return ED visits and fewer complications. This makes it an attractive alternative treatment option for abscesses. [ABSTRACT FROM AUTHOR]