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Abstract Background Emergency departments increasingly serve patients who prefer a language other than English. Honoring patients’ language preferences is crucial for quality and cultural appropriateness of care. We sought to assess whether time spent in caring for patients who preferred a language other than English differed from patients whose language preference was English. Secondarily, we sought to assess professional reimbursement across the two groups. Methods We retrospectively analyzed an existing dataset from a time‐in‐motion study that included direct observation measurements of emergency physicians’ time spent during patient encounters. Our primary outcome was physician time spent conducting patient care, comparing patients who preferred a language other than English to patients who preferred English. Secondarily, we sought to assess if relative value unit (RVU)‐based compensation differed across the two groups. We calculated descriptive statistics and performed multivariable regression. Results Across 218 patient encounters, physicians spent 18.6% longer on encounters with patients whose preferred a language other than English (median = 18.5 min, interquartile range [IQR] 14.8–27.9 min) than for those who preferred English (median = 15.6 min, IQR 11.5–22.9 min; p = 0.04). After controlling for other factors, patients’ preferred language was not associated with increased RVUs (β = −0.12, t = −1.94, p = 0.055). Conclusions Emergency physicians appear to spend more time caring for patients who prefer a language other than English. This additional effort during the care of this potentially vulnerable population may not be reflected in past and current reimbursement structures. Additional research is prudent as we seek to better address social determinants of health in care delivery and reimbursement systems.

Introduction: We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics. Methods: We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates. Results: There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020–May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment. Conclusion: Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.

Abstract Objectives To evaluate whether subcutaneous neutralizing monoclonal antibody (mAb) treatment given in the emergency department (ED) setting was associated with reduced hospitalizations, mortality, and severity of disease when compared to nontreatment among mAb‐eligible patients with coronavirus disease 2019 (COVID‐19). Methods This retrospective observational cohort study of ED patients utilized a propensity score‐matched analysis to compare patients who received subcutaneous casirivimab and imdevimab mAb to nontreated COVID‐19 control patients in November–December 2021. The primary outcome was all‐cause hospitalization within 28 days, and secondary outcomes were 90‐day hospitalization, 28‐ and 90‐day mortality, and ED length of stay (LOS). Results Of 1340 patients included in the analysis, 490 received subcutaneous casirivimab and imdevimab, and 850 did not received them. There was no difference observed for 28‐day hospitalization (8.4% vs. 10.6%; adjusted odds ratio [aOR] 0.79, 95% confidence intervals [CI] 0.53–1.17) or 90‐day hospitalization (11.6% vs. 12.5%; aOR 0.93, 95% CI 0.65–1.31). However, mortality at both the 28‐day and 90‐day timepoints was substantially lower in the treated group (28‐day 0.6% vs. 3.1%; aOR 0.18, 95% CI 0.08–0.41; 90‐day 0.6% vs. 3.9%; aOR 0.14, 95% CI 0.06–0.36). Among hospitalized patients, treated patients had shorter hospital LOS (5.7 vs. 11.4 days; adjusted rate ratio [aRR] 0.47, 95% CI 0.33–0.69), shorter intensive care unit LOS (3.8 vs. 10.2 days; aRR 0.22, 95% CI 0.14–0.35), and the severity of hospitalization was lower (aOR 0.45, 95% CI 0.21–0.97) compared to untreated. Conclusions Among ED patients who presented for symptomatic COVID‐19 during the Delta variant phase, ED subcutaneous casirivimab/imdevimab treatment was not associated with a decrease in hospitalizations. However, treatment was associated with lower mortality at 28 and 90 days, hospital LOS, and overall severity of illness.

Abstract Objectives Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time‐sensitive condition, acute stroke. Methods We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door‐to‐activation (DTA) time (ie, ED arrival [“door”] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician. Results Among 462 stroke activation patients in 2014–2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off‐service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3–2.3) and 0.7 (IQR, 0–1), respectively. A 1‐resident increase in off‐service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64–0.90) in the probability of stroke team activation at any given time. An independent 1‐resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01–1.25) in timely activation. Conclusion Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off‐service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.

Abstract Background Academic and non-academic emergency departments (EDs) are regularly compared in clinical operations benchmarking despite suggestion that the two groups may differ in their clinical operations characteristics. and outcomes. We sought to describe and compare clinical operations characteristics of academic versus non-academic EDs. Methods We performed a descriptive, comparative analysis of academic and non-academic adult and general EDs with 40,000+ annual encounters, using the Academy of Academic Administrators of Emergency Medicine (AAAEM)/Association of Academic Chairs of Emergency Medicine (AACEM) and Emergency Department Benchmarking Alliance (EDBA) survey results. We defined academic EDs as primary teaching sites for emergency medicine (EM) residencies and non-academic EDs as sites with minimal resident involvement. We constructed the academic and non-academic cohorts from the AAAEM/AACEM and EDBA surveys, respectively, and analyzed metrics common to both surveys. Results Eighty and 454 EDs met inclusion criteria for academic and non-academic EDs, respectively. Academic EDs had more median annual patient encounters (73,001 vs 54,393), lower median proportion of pediatric patients (6.3% vs 14.5%), higher median proportion of EMS patients (27% vs 19%), and were more commonly designated as Level I or II Trauma Centers (94% vs 24%). Median patient arrival-to-provider times did not differ (26 vs 25 min). Median length-of-stay was longer (277 vs 190 min) for academic EDs, and left-before-treatment-complete was higher (5.7% vs 2.9%). MRI utilization was higher for academic EDs (2.2% patients with at least one MRI vs 1.0 MRIs performed per 100 patients). Patients-per-hour of provider coverage was lower for academic EDs with and without consideration for advanced practice providers and residents. Conclusions Demographic and operational performance measures differ between academic and non-academic EDs, suggesting that the two groups may be inappropriate operational performance comparators. Causes for the differences remain unclear but the differences appear not to be attributed solely to the academic mission.

Introduction: Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified–those arriving by private vehicle. Methods: We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of ≤15 minutes, controlling for a variety of clinical factors. Results: Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27–0.96) for achieving DTA ≤ 15 minutes. Conclusion: Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition.

Introduction: Emergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed “Code Help.” Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed. Methods: This was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations. Results: Of 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations. Conclusion: In this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.