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Objectives: Emergency department (ED) patients with serious skin and soft tissue infections (SSTIs) are often hospitalized to receive intravenous (IV) antibiotics. Appropriate patients may avoid admission following a single‐dose, long‐acting IV antibiotic. Methods: We conducted a preintervention versus postintervention design trial at 11 U.S. EDs comparing hospitalization rates under usual care to those using a clinical pathway that included a single IV dalbavancin dose. We enrolled adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm2 without other indications for hospitalization. Clinical pathway participants discharged from the ED received a 24‐hour follow‐up telephone call and had a 48‐ to 72‐hour in‐person visit. We hypothesized that, compared to usual care, the clinical pathway would result in a significant reduction in the initial hospitalization rate. Results: Of 156 and 153 participants in usual care and clinical pathway periods, median infection areas were 255.0 (interquartile range [IQR] = 150.0 to 500.0) cm2 and 289.0 (IQR = 161.3 to 555.0) cm2, respectively. During their initial care, 60 (38.5%) usual care participants were hospitalized and 27 (17.6%) pathway participants were hospitalized (difference = 20.8 percentage points [PP], 95% confidence interval [CI] = 10.4 to 31.2 PP). Over 44 days, 70 (44.9%) usual care and 44 (28.8%) pathway participants were hospitalized (difference = 16.1 PP, 95% CI = 4.9 to 27.4 PP). Conclusions: Implementation of an ED SSTI clinical pathway for patient selection and follow‐up that included use of a single‐dose, long‐acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections. Registration: NCT02961764. [ABSTRACT FROM AUTHOR]

Background: Cutaneous abscesses are common presentations to the emergency department. While the primary treatment for most abscesses is conventional incision and drainage (CID), this is painful and can lead to multiple return visits. The loop drainage technique (LDT) has been proposed as an alternate, less‐invasive approach to abscess management. The primary outcome of this study was to compare LDT with CID for skin and soft tissue abscesses. Methods: PubMed, Scopus, CINAHL, LILACS, Google Scholar, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all retrospective, prospective observational, and randomized controlled trials comparing treatment failures between LDT and CID among patients with skin and soft tissue abscesses. Data were dual extracted into a predefined worksheet and quality analysis was performed using the Cochrane Risk of Bias tool or the Newcastle‐Ottawa scale. Data were summarized and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Subgroup analyses were performed for adult and pediatric patients. Results: A total of 1,374 studies were identified with eight studies (n = 910 patients) selected for inclusion. Overall, CID failed in 69 of 487 patients (14.17%), while LDT failed in 35 of 423 patients (8.27%). There was an OR of 2.02 (95% CI = 1.29 to 3.18) in favor of higher failures in the CID group. This finding remained consistent with only randomized controlled trials (OR = 1.75, 95% CI = 1.07 to 2.86), but no difference was identified in the adult or pediatric subgroups. Conclusion: The LDT was associated with reduced treatment failures when compared with CID. Future studies should further assess the impact on pain, cosmetic outcomes, and health care costs. [ABSTRACT FROM AUTHOR]

Objectives: We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). Methods: We conducted a before‐and‐after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017–May 2018) and after (December 2018–May 2019) opening an EmPATH unit. These are outpatient hospital‐based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt–Winters method was used to forecast pre‐EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre‐EmPATH expected and post‐EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. Results: There were 23,231 and 23,336 ED visits evaluated during the pre– and post–EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119–536) minutes to 152 (86–307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204–631) minutes to 334 (212–517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes). Conclusion: The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients. [ABSTRACT FROM AUTHOR]

Objectives: Patients with cannabinoid hyperemesis syndrome (CHS) present frequently to the emergency department. Previous case studies suggest dramatic symptomatic improvement with topical capsaicin treatment. This exploratory study examined the potential effectiveness of topical capsaicin in patients with nausea and vomiting due to a suspected CHS exacerbation. Methods: This was a double‐blind, randomized placebo‐controlled pilot trial. Adults who presented with vomiting suspected to be from CHS were eligible for enrollment. We excluded pregnant women and those with resolution of symptoms. Following randomization, topical 0.1% capsaicin or placebo cream was applied to the anterior abdomen in a uniform manner. The primary outcome was the severity of nausea on a visual analog scale (VAS) of 0 to 10 cm assessed at 30 minutes. Secondary outcomes were adverse events, occurrence of posttreatment vomiting, nausea by VAS at 60 minutes, and hospital admission. Results: This pilot trial enrolled 30 patients, 17 in the capsaicin arm and 13 in the placebo arm. One patient in the capsaicin arm did not tolerate treatment due to skin irritation. Mean ± SD nausea severity at 30 minutes was 4.1 ± 2.3 cm in the capsaicin arm and 6.1 ± 3.3 cm in the placebo arm (difference = −2.0 cm, 95% confidence interval [CI] = 0.2 to −4.2 cm). At 60 minutes, mean ± SD nausea severity was 3.2 ± 3.2 cm versus 6.4 ± 2.8 cm (difference = −3.2 cm, 95% CI = −0.9 to −5.4 cm). The percent reduction in nausea at 60 minutes from baseline was 46.0% in the capsaicin arm and 24.9% in the placebo arm (difference = 21.1%, 95% CI = −5.6% to 47.9%). A higher proportion of capsaicin group patients (29.4% vs. 0%) had complete resolution of nausea (relative risk = 3.4, 95% CI = 1.6 to 7.1). Conclusion: In this pilot trial, the application of topical capsaicin cream was associated with a significant reduction in nausea at 60 minutes but not at 30 minutes and provided more complete relief of nausea. [ABSTRACT FROM AUTHOR]

The article discusses the impact of heat waves on emergency department visits in Roanoke, Virgin. Topics discussed include Prior heat-related research has emphasized the impact of heat events on mortality, but there is a growing interest in understanding the influence of heat on emergency department (ED) visits; and potential cause of morbidity, traditional data set filtering by heat stress codes results in a significant underestimate of the actual heat impact.

Background: Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations. Methods: This prospective cohort study enrolled a convenience sample of English‐speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD‐MDD) and dimensional depression severity measurement test (CAT‐DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes. Results: Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06–2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5‐fold increase in the rate of ED visits and hospitalization rates. Conclusions: Rates of depression were high among a convenience sample of English‐speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) visits provide an opportunity for hepatitis C virus (HCV) screening for patients who otherwise might not be tested. We report on a novel nontargeted, opt‐out HCV screening and linkage‐to‐care (LTC) program implemented in an urban ED. Methods: This is a descriptive analysis from 3 months (November 2016–January 2017) of a nontargeted, opt‐out ED HCV screening and LTC program among patients at least 13 years old undergoing phlebotomy for clinical purposes. A multipurpose best practice advisory (BPA) alerted providers to the program and generated order labels. For patients who authorized testing, specimens were drawn in the ED for HCV antibody (Ab) and reflex confirmatory RNA tests. Public health navigators attempted to contact RNA‐positive patients and arrange outpatient visits. Results: HCV Ab tests were performed on 3,808 patients, a 6,950% increase from preprogram. The proportion of HCV Ab test positivity was 13.2% (504/3,808, 95% confidence interval [CI] = 12.2%–14.3%) and of those 97.8% (493/504) had a follow‐up RNA test performed. A total of 292 were confirmed positive for active infection, for an overall RNA positivity rate of 7.7% (95% CI = 6.8%–8.5%). Of those with active infection, 155 (53%) were outside the Centers for Disease Control and Prevention birth cohort for increased risk for HCV including 46 (15.8%, 95% CI = 11.8%–20.4%) who also did not report injection drug use. Linkage attempts were documented on 223 (76.4%) patients and appointments were scheduled for 102 (38% of attempted). Sixty‐six patients attended their LTC visit (22.5% of all RNA‐positive patients, 30% of linkage‐eligible patients). Conclusions: Nontargeted opt‐out HCV testing can be successfully implemented in an ED setting. A number of patients diagnosed were outside traditional risk groups. Once diagnosed, an ED population may be difficult to engage in care, but a structured interdisciplinary program can successfully link patients to HCV care. [ABSTRACT FROM AUTHOR]

Background Anxiety and depression rates among emergency department ( ED) patients are substantially higher than those in the general population. Additionally, those with mental health issues often have difficulty accessing care. Unfortunately, issues of anxiety and depression are frequently not addressed in the ED due to competing care priorities. This may lead to increased burden and overcrowding in EDs. Objective This study related anxiety and depression with ED utilization and perceived barriers to care. Methods To limit the impact of insurance coverage on ED utilization and access to care, a convenience sample of adults 45 to 85 years of age in the ED were surveyed. The Generalized Anxiety Disorder 7 and Patient Health Questionnaire 9 were used to measure anxiety and depression. Results A total of 251 subjects were enrolled. Severe anxiety was observed in 10% of patients, while moderately severe or severe depression was observed in 12%. Patients who were both severely anxious and depressed visited the ED nearly twice as often as nonanxious and nondepressed patients. The majority of patients cited at least one moderate barrier to care, and greater anxiety and depression scores were related to greater perceived barriers to care. Perceived barriers to care were more than three times higher among patients who were both anxious and depressed compared to those in patients who were neither depressed nor anxious and twice as high as in those who were either depressed or anxious (p < 0.001). Conclusion Patients identified with internalizing mental health concerns utilize the ED at elevated rates while also reporting the greatest difficulties accessing care. These findings highlight the need for ED interventions aimed at identifying patient mental health concerns, as well as perceived barriers to care, to design interventions to effectively improve continuity of care. [ABSTRACT FROM AUTHOR]

Objective Delayed diagnosis of Kawasaki disease ( KD) may lead to serious cardiac complications. We sought to create and test the performance of a natural language processing ( NLP) tool, the KD- NLP, in the identification of emergency department ( ED) patients for whom the diagnosis of KD should be considered. Methods We developed an NLP tool that recognizes the KD diagnostic criteria based on standard clinical terms and medical word usage using 22 pediatric ED notes augmented by Unified Medical Language System vocabulary. With high suspicion for KD defined as fever and three or more KD clinical signs, KD- NLP was applied to 253 ED notes from children ultimately diagnosed with either KD or another febrile illness. We evaluated KD- NLP performance against ED notes manually reviewed by clinicians and compared the results to a simple keyword search. Results KD- NLP identified high-suspicion patients with a sensitivity of 93.6% and specificity of 77.5% compared to notes manually reviewed by clinicians. The tool outperformed a simple keyword search (sensitivity = 41.0%; specificity = 76.3%). Conclusions KD- NLP showed comparable performance to clinician manual chart review for identification of pediatric ED patients with a high suspicion for KD. This tool could be incorporated into the ED electronic health record system to alert providers to consider the diagnosis of KD. KD- NLP could serve as a model for decision support for other conditions in the ED. [ABSTRACT FROM AUTHOR]