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Importance: Oral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results., Objective: To evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients., Design, Setting, and Participants: The Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O'CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase., Intervention: Physician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up., Main Outcomes and Measures: The main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient., Results: A total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008)., Conclusions and Relevance: In this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF., Trial Registration: ClinicalTrials.gov Identifier: NCT05009225.

Introduction There is considerable variation in the approach to infants presenting to the emergency department (ED) with fever. The authors' primary aim was to develop a robust set of algorithms using community ED data to inform modifications of broader clinical guidance. Methods The authors report the development of California Febrile Infant Risk Stratification Tool (CA FIRST) using key components of the Roseville Protocol (ROS) and American Academy of Pediatrics (AAP) Clinical Practice Guideline (CPG). Expanded guidance was derived using a retrospective analysis of a cohort of 3527 febrile infants aged 7-90 days presenting to any Kaiser Permanente Northern California ED between 2010 and 2019 who underwent a core febrile infant evaluation. Results Melding ROS and AAP CPG algorithms in infants 7-60 days old, CA FIRST Algorithms had comparable performance characteristics to ROS and AAP CPG. CA FIRST enhancements included guidance on febrile infants 61-90 days old, high-risk infants, infants with bronchiolitis, and infants who received immunizations within the prior 48 hours. This retrospective analysis revealed that of 235 febrile infants 22-90 days old with respiratory syncytial virus and 221 who had fever in the 48 hours following vaccination, there were no cases of invasive bacterial infection. Discussion CA FIRST is a set of 13 algorithms providing a thoughtful and flexible approach to the febrile infant while minimizing unnecessary interventions. Conclusions CA FIRST Algorithms empower clinicians to manage most febrile infants. Algorithms are being modified as new data become available, imparting useful and ever-current educational information within a learning health care system., Competing Interests: Conflicts of Interest None declared

Background: Sharps waste, especially medical sharps waste, can put those who come into contact with it at risk for injury and exposure to blood-borne pathogens. Options for self-injectors to dispose of their sharps while traveling vary greatly - from sharps containers in limited locations in some public restrooms to large kiosks centrally located to no containers at all. Currently, there is a lack of published data on sharps disposal bins in commercial airports. We surveyed commercial airports in California to assess the current state of sharps waste disposal. Many people with diabetes routinely use sharps every day for injecting medications or for self-monitoring glucose concentrations and these people, along with others who self-inject medications, must have a safe mechanism for sharps disposal when travelling by air., Methods: A five-question survey was sent to 30 commercial airports in California. Responses were collected and then analyzed based on the following three metrics: (1) the percentage of airports that responded and indicated that they had any sharps disposal bins, (2) the percentage of airports that responded and indicated that they had sharps disposal bins in over half their restrooms, and (3) the average percentage of bathrooms that have available sharps disposal bins in airports that responded to our survey., Results: Out of 30 commercial airports in California, we received survey responses from 13 airport representatives and direct email responses from 5 airport representatives. Out of 18 total responses, 11 airports (61.1%) reported that they had some form of available sharps disposal options. Out of the 13 survey responses, 6 airports (46.2%) reported that they had sharps disposal in over 50% of their restrooms., Conclusion: There is a lack of consistency in sharps waste disposal options among commercial airports in California. While many commercial airports in California offer sharps waste disposal options, not all commercial airports have sharps waste disposal options in all their public restrooms. There is room for improved availability of sharps disposal bins in California's commercial airports.