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Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.

Background Febrile neutropenia (FN) is an important oncological emergency seen in the emergency department (ED), and the American Society of Clinical Oncology recommends risk stratification of patients with febrile neutropenia using the Multinational Association for Supportive Care in Cancer (MASCC) Index, with ED discharge on oral antibiotics recommended for low-risk patients. Objectives To determine the prevalence of FN neutropenia and medical system wide ED treatment guideline adherence. Methods We performed a retrospective chart review of all patients with an ICD-10 confirmed diagnosis of FN from January 2016-2019at 13 affiliated EDs within one medical system. Only cancer/chemotherapy related FN were included. Following the MASCC guidelines, we used post-hoc calculations to classify patients as low/high-risk, and compared key clinical variables (mortality, blood culture positivity, interventions). Results 203 patients were found to have FN. 97.9% (184/203) received broad spectrum antibiotics, including 92% of the low-risk group (60/65). All patients were admitted, and no observed in-hospital mortality was noted in the low-risk group, meanwhile 5.1% (7/138) of the high-risk group died. 14/203 patients had positive blood cultures, none in the low-risk group. Conclusion The prevalence of FN is low among 13 EDs that had almost 1.7 million ED visits over a 3-year period. Guideline compliance for low-risk FN was poor. All patients were admitted, and nearly all patients received IV fluids and IV antibiotics. Improving FN management to align with national guidelines represents an opportunity to improved ED care of patients with cancer by reducing unnecessary hospitalizations.

The Emergency Department (ED) plays a key role in the identification and care of acute medical conditions, including cancer. In this scoping review, we aimed to determine the role of the ED in the acute diagnosis of cancer.We conducted a scoping review of articles according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) using PubMed and Google Scholar. We screened studies of adults with a new diagnosis of cancer in the ED. We included randomized control trials, prospective, retrospective, and cross-sectional observational studies, and case reports published in English since 2000. We grouped the articles into categories based on their objectives and findings.Of the 4459 articles, we included 47 in the review. The identified studies fell into three major categories: (1) studies describing the incidental diagnosis of cancer in the ED (n = 11, 23%), (2) studies characterizing the acute initial presentation of cancer in the ED (n = 19, 41%), and (3) studies describing the ED as a pathway to cancer diagnosis in the healthcare system (n = 17, 36%). Across the studies, cancer diagnoses in the ED were more likely in patients with higher comorbidities, occurred at later stages, and resulted in worse survival rates.The ED plays a prominent role in the initial diagnosis of cancer. Efforts must be made to integrate the ED within the cancer care continuum.

Pain is common in patients with cancer seeking emergency department (ED) care. Fifty percent of ED patients with cancer present with pain and 39% report pain at final ED pain assessment. Thus, ED practitioners seemingly remain challenged to manage pain in this population. Such findings support calls encouraging safe, effective, and timely pain management in EDs. Brown and colleagues encourage research into any racial or socioeconomic gaps in the treatment of pain in ED cancer patients.

BACKGROUND: The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for pre-implementation planning. METHODS: The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC. RESULTS: Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often don’t remember (n=27, 58.7%) and It is not a priority (n=14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were: identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention. CONCLUSION: CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This pre-implementation process could be replicated in other EDs considering implementing geriatric screening.

Purpose Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC). Methods A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods. Results During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5). Conclusions This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.

BACKGROUND: Older adults with cancer use the emergency department (ED) for acute concerns. OBJECTIVES: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. DESIGN: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. SETTINGS/SUBJECTS: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. MEASUREMENTS: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. RESULTS: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54–71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0–7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0–3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2–10.4]). CONCLUSIONS: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.

Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Author(s): Hunold, Katherine M.; Caterino, Jeffrey M.; Bischof, Jason J. | Abstract: Objective: Dyspnea is the second most common symptom experienced by the approximately 4.5 million patients with cancer presenting to emergency departments (ED) each year. Distinguishing pneumonia, the most common reason for presentation, from other causes of dyspnea is challenging. This report characterizes the diagnostic uncertainty in patients with dyspnea and pneumonia presenting to an ED by establishing the rates of co-diagnosis, co-treatment, and misdiagnosis.Methods: Visits by individuals ≥18 years old with cancer who presented with a complaint of dyspnea were identified using the National Hospital Ambulatory Medical Care Survey between 2012-2014 and analyzed for rates of co-diagnosis, co-treatment (treatment or diagnosis for g1 of pneumonia, chronic obstructive pulmonary disease [COPD], and heart failure), and misdiagnosis of pneumonia. Additionally, we assessed rates of diagnostic uncertainty (co-diagnosis, co-treatment, or a lone diagnosis of dyspnea not otherwise specified [NOS]) .Results: Among dyspneic cancer visits (1,593,930), 15.2% (95% confidence interval [CI], 11.1-20.5%) were diagnosed with pneumonia, 22.5% (95% CI, 16.7-29.7%) with COPD, and 7.4% (95% CI 4.7-11.4%) with heart failure. Dyspnea NOS was diagnosed in 32.3% (95% CI, 25.7-39.7%) of visits and as the only diagnosis in 23.1% (95% CI, 16.3-31.6%) of all visits. Co-diagnosis occurred in 4.0% (95% CI, 2.0-7.6%) of dyspneic adults with cancer and co-treatment in 12.1% (95% CI, 7.5-18.9%). Agreement between emergency physician and inpatient documentation for presence of pneumonia was 57.7% (95% CI, 37.0-76.1%).Conclusion: Diagnostic uncertainty remains a significant concern in patients with cancer presenting to the ED with dyspnea. Clinical uncertainty among dyspneic patients results in both misdiagnosis and under-treatment of patients with pneumonia and cancer.

OBJECTIVES: Emergency medicine (EM) residents take the In‐Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016–2018 to the content of the EM Model represented by the ITE Blueprint. METHODS: This was a retrospective cross‐sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs). RESULTS: Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident. CONCLUSIONS: Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.

There is a high prevalence of opioid use disorder in the United States, and emergency departments (EDs) play multiple vital roles in providing care to help these patients with achieving sobriety, one of which is the application of peer recovery services. This technical report discusses the utilization of peer recovery supporters in the ED and associated barriers. They include but are not limited to the difficult hiring process, referral process challenges for certain populations, difficulty with follow-up data collection, retention of peer recovery supporters, and a lack of ED provider awareness. This article also discussed strategies to address these barriers. Examples include simplifying hospital onboarding processes for peer recovery supporters, obtaining grants to utilize peer recovery services, and using managed care organizations to facilitate follow-up data collection, ED provider education, and discharge planning.

Patients with cancer represent a growing population of patients seeking acute care in emergency departments (ED) nationwide. Emergency physicians are expected to provide excellent, consistent care to all ED patients; however, emergency medicine (EM) education and training of acute oncology is lacking.To explore this topic, the Society for Academic Emergency Medicine Oncologic Emergencies Interest Group recruited experts in the field to provide a narrative description of the current state of EM education relating to acute oncology. This review of expert opinions explores the current state of acute oncology education in EM and identifies key content gaps that merit early investment.Current emergency physician training and knowledge relating to acute oncology likely reflects the American Board of Emergency Medicine Model of Clinical Practice. Key topics such as immunotherapy are absent from the most recent revision of the Model of Clinical Practice and consequently represent a knowledge gap for large numbers of emergency physicians. Additionally, there is limited penetration of guideline-based care for symptom management in the ED setting. As such, additional attention should be provided to training programs and research efforts to address these knowledge gaps.In conclusion, the current state of acute oncology education and training of emergency physicians is lacking and merits significant investment to assure the ability of emergency physicians to provide superior care for the growing population of patients with cancer.

Author(s): San Miguel, Christopher E.; Leung, Cynthia; Kman, Nicholas; Bischof, Jason | Abstract: This journal club style curriculum was developed to advance 4th year medical students in Emergency Medicine (EM) Milestone 19. The curriculum was introduced as part of a longitudinal boot camp course for EM- bound students. Students met monthly with faculty members to critically evaluate landmark articles within the field of EM. The curriculum culminated with student group presentations of two contemporary research articles with opposing conclusions. Discussed articles covered the following topics: stroke care, head trauma, cervical spine trauma, pulmonary embolism, cardiology treatments, syncope, post- cardiac arrest care, pediatrics, sepsis, and fluid resuscitation. The curriculum was evaluated using the institution’s standard student educational session evaluation form. Students rated the quality of the sessions highly, and based on thematic review of comments, the journal club was a beneficial addition to the boot camp curriculum.

Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer.Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017.Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics.We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.

Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.

Objectives National data reveal that 60% of the 4.5 million annual emergency department (ED) visits by patients with cancer result in admission. Many of these visits are due to a febrile illness. Current literature provides limited guidance on how to treat non‐neutropenic febrile ED patients. This study characterizes clinical outcomes of non‐neutropenic febrile patients with cancer presenting to an academic, Comprehensive Cancer Center affiliated ED. Methods Retrospective chart review of 101 randomly selected adult patients with active cancer presenting with a chief complaint of fever or a documented fever in the ED and an absolute neutrophil count above 1000 between October 2015 and September 2016. Descriptive statistics were calculated. Results The primary malignancies represented were hematologic (24%), gastrointestinal (13%), head and neck (13%), and genitourinary (8%). Sixty‐two percent were on chemotherapy, 15% on radiation therapy, and 12% were on targeted therapy. Severe illness outcomes occurred in 39% and 83% were admitted with a median length of stay of 4 days. Among admitted patients, 24% experienced a length of stay ≤2 days. A return visit to the ED or an in‐system hospitalization within 7 days of the index visit occurred in 10% and death occurred within 7 days of the index visit in 4%. Conclusion A majority of patients presenting to the ED with non‐neutropenic fever are admitted (83%), of whom nearly a quarter experience a length of stay of ≤2 days with infrequent serious illness outcomes. Future efforts should focus on the development of risk stratification tools in this population to avoid potentially unnecessary hospitalizations.

BACKGROUND: Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. OBJECTIVES: To evaluate the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. METHODS: We conducted a pre-specified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive ONCologic Emergencies Research Network’s (CONCERN) multicenter (18 sites) study of ED visits by patients with active cancer (N=1075). We used a series of X(2) tests for independence to relate ESI scores with (a) disposition, (b) ED resource utilization, (c) hospital length of stay, and (d) 30-day mortality. RESULTS: Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily towards high acuity (>95% were ESI 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p’s < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. CONCLUSION: ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource utilization. These findings demonstrate that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

Emergency departments (EDs) care for patients with complex medical problems who require a coordinated care approach. Patient navigation services, which help assist patients with care coordination, have been widely implemented for patients with cancer in a variety of settings, but this approach has not been described in the ED. We sought to better understand the potential for ED-based patient navigation services from the perspective of individuals currently providing these services in other settings. A survey was conducted of participants at a regional conference for patient navigation services of patients with cancer. Eighty-five completed surveys were returned representing a response rate of 64%. Ninety-one percent of responses indicated that lay navigation services would be either very helpful or moderately helpful for either ED patients with cancer or for ED patients aged 65 years or older with or without cancer in an ED. Coordination of care, the provision of emotional support and educational resources relevant to their medical conditions, and providing companionship to older patients during the ED visits were identified as priorities for an ED-based lay navigation program. The lack of navigators with experience in the ED, the physical space constraints of the ED, and the time constraints associated with an ED visit were identified as the primary barriers to establishing a lay navigation program in the ED. These results identify the care priorities and barriers to be overcome during the development of an ED-based lay navigation program from the perspective of those currently providing patient navigator services.

Supplemental Digital Content is Available in the Text., Background: There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Setting: Multicenter registry of patients from 116 emergency departments in 27 US states. Methods: Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan–Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status. Results: Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01). Conclusions: Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

Background: Around 1 million United States emergency department (ED) visits per year are due to exacerbation of heart failure (HF) symptoms, with ~80% of those patients admitted to the hospital. However, sex and age differences in HF symptom presentation in the ED have not been thoroughly investigated. Objectives: To describe sex and age differences in chief complaints of ED patients with a HF diagnosis. Methods: We included patients ≥18 years old with an ED diagnosis of HF in NC DETECT, a statewide syndromic surveillance system. We defined a HF diagnosis using ICD-9-CM and ICD-10-CM codes from ED visits between 2010 and 2016. We classified the ED chief complaints into categories by symptom groups (e.g. respiratory complaint includes hypoxia, respiratory distress, breathing difficulties). Chief complaint categories are not mutually exclusive. We calculated frequencies of chief complaint categories for ED visits by sex and age (18-44 (n=55,216), 45-64 (n=260,397), ≥65 (n=578,313) years old) and evaluated for a 10% standardized difference between groups. Results: There were 422,720 patients with 893,950 total unique visits (1.6 average visits/person). Of these visits, 55.0% were by women and 59.5% patients were admitted. Overall, the top chief complaint categories were dyspnea (19.1%), chest pain (13.5%), and respiratory complaints (13.4%), and were similar by sex and by ED disposition (admitted or discharged) and sex. When stratified by sex and age group, in those 18-44 years old, women had more reports of nausea/vomiting (6.7%) compared with men (4.1%) and headache (4.2%) compared with men (2.0%). In those 45-64 and ≥65 years old, chief complaint categories were similar between women and men. When stratified by age group alone, reports of chest pain decreased with age (21.4% in 18-44, 17.7% in 45-64, and 10.8% in ≥65 year olds), whereas reports of balance issues (1.2% in 18-44, 2.4% in 45-64, and 6.0% in ≥65 year olds), weakness (1.7% in 18-44, 2.7% in 45-64, and 5.5% in ≥65 year olds), and confusion (0.8% in 18-44, 2.1% in 45-64, and 4.5% in ≥65 year olds) increased with age. Compared to those ≥65 years old, those 18-44 years old had fewer respiratory complaints (10.0% vs. 13.9%), but more reports of headache (3.2% vs. 0.8%) and nausea/vomiting (5.5% vs. 3.2%). Conclusion: In a state-wide population of ED patients with HF diagnoses, sex differences in chief complaint categories that are less obvious symptoms of HF were observed for those 18-44 years old, with women reporting more nausea/vomiting and headache compared to men. Chief complaint categories that are less obvious symptoms of HF were more common among patients 18-44 (nausea/vomiting, headache) and ≥65 (balance issues, confusion, weakness) years old. Characterizing the variation of symptoms of HF patients in the ED may help inform the identification of ED patients with HF and the outpatient management of HF-related symptoms.

Background The use of computed tomography (CT) has been scrutinized in emergency medicine, particularly in patients with cancer. Previous studies have characterized the rate of CT use in this population; however, limited data are available about the yield of this modality compared with radiography and its clinical decision-making effect. Objective To determine whether CT imaging of the chest increases identification of clinically significant results compared with chest radiography (CXR) in patients with cancer. Methods This was a retrospective chart review of patients with a history of solid tumors presenting to an emergency department in 2017. Patients who received both CXR and CT (or CT angiography) of the chest during their assessment were identified and the rate of clinically significant findings on imaging was compared. Clinical findings were further categorized as requiring nonurgent, urgent, or emergent attention. Descriptive statistics and chi-squared testing were performed between the 2 imaging modalities. Results From 839 patients meeting inclusion criteria, 287 were randomly sampled. The predominant malignancies were lung (32.4%), breast (13.9%), and head and neck cancer (13.6%). A greater number of patients had clinically significant findings identified on CT imaging (n = 222) compared with CXR (n = 108). Stratification upon urgency of these findings (nonurgent, urgent, or emergent) reveals a significant difference in all strata (p Conclusions Compared with CXR, CT imaging of the chest identified significantly more clinically relevant findings requiring attention and consequently affecting clinical decision making.

OBJECTIVE: Elder abuse is a common and morbid condition that often goes undetected. While emergency medical service (EMS) providers have a unique opportunity to identify elder abuse, interviews with these providers suggest that a lack of instruction specific to elder abuse limits their potential to identify the problem and take appropriate action. This study describes statewide EMS protocols relating to identification, management, and reporting of elder abuse in the prehospital setting. DESIGN: Cross-sectional analysis. SETTING: Statewide EMS protocols in the United States. PARTICIPANTS: Publicly available statewide EMS protocols identified from 1) published literature 2) EMSprotocols.org, and 3) each state’s public health website. MEASUREMENTS: Protocols were reviewed to determine if (1) elder abuse was mentioned, (2) elder abuse was defined, (3) potential indicators of elder abuse were listed, (4) patient management for older adults experiencing abuse was described, and (5) instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison. RESULTS: Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Examining protocols that do mention elder abuse, 6/14 (42.9%) define elder abuse, 10/14 (71.43%) describe indicators of elder abuse, 8/14 (57.1%) provide instruction regarding patient management, and 12/14 (85.7%) provide instruction regarding reporting. By comparison, almost twice as many states met each of these metrics for child abuse. CONCLUSION: Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content at all on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.

Study Objective: The COVID-19 pandemic caused by the severe acute respiratory coronavirus 2 (SARS-CoV-2) has significantly affected the provision of routine and acute medical care. The aim of this report is to characterize patients with cancer presenting to EDs in the United States and COVID-19 mortality risk according to tumor subtype. Methods: The RECOVER registry represents a collaboration between 45 EDs spanning 27 states. This retrospective registry enrolled patients from each study site who received molecular diagnostic testing as part of ED care due to clinical suspicion for COVID-19 disease. Clinical characteristics pertaining to a patient’s cancer status were obtained from medical record review, specifically cancer type, active versus remission status, metastatic versus isolated tumor, and hematologic versus solid tumor status. Cancer type was further classified as solid/hematologic tumor localized or metastatic based on documented diagnoses and/or past medical history. Results: There are a total of 2865 patients who have a reported history of cancer, 1899 (66.3%) were negative for COVID-19 and 33.7% were positive on COVID-19 testing. There are higher percentages of minority-identifying patients in the COVID-19 positive cohort as compared to the negative cohort, namely Black or African American (33.9% vs 13.5%, respectively, p

Introduction Intravascular volume status is an important clinical consideration in the management of the critically ill. Point of care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there is limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation is to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”). Methods Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and Motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, descriptive statistics, intra-class correlation coefficients (ICC), and 2-Way Univariate Analyses of Variance (ANOVA) were calculated. Results Thirty-nine volunteers were evaluated yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI = 0.76 to 0.92) while CLA had the poorest ICC (0.74, 95% CI = 0.56 to 0.85). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses reveal difficulty in consistent view acquisition between EPs. Conclusions Inter rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.

Diagnosing rashes in the emergency department can be challenging. If the rash is extensive and targetoid, include Stevens-Johnson Syndrome (SJS) on your differential and be sure to obtain a thorough history to identify possible offending agents. Additionally, prioritize supportive care and obtaining a dermatology/burn consult to coordinate appropriate care.

OBJECTIVE: The American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (ABEM Model) serves as a guide for resident education and the basis for the resident In‐training Examination (ITE) and the Emergency Medicine Board Qualification Examinations. The purpose of this study was to determine how closely resident–patient encounters in our emergency departments (EDs) matched the ABEM Model as presented in the specifications of the content outline for the ITE. METHODS: This single‐site study of an academic residency program analyzed all documented resident–patient encounters in the ED during a 2.5‐year period recorded in the electronic medical record. The chief complaints from these encounters were matched to the 20 categories of the ABEM Model. Chi‐square goodness‐of‐fit tests were performed to compare the proportions of categorized encounters and proportions of patient acuity levels to the proportions of categories as outlined in the content blueprint of the ITE. RESULTS: After the exclusion of encounters with missing data and those not involving EM residents, 125,405 encounters were analyzed. We found a significant difference between the clinical experience of EM residents and the ABEM Model as reflected in the ITE for both case categories (p

Key Points Question What are the characteristics of patients with active cancer presenting to US emergency departments? Findings In this multicenter cohort study of 1075 adult patients with active cancer in the Comprehensive Oncologic Emergencies Research Network (CONCERN), patients commonly presented with symptoms such as pain (62.1%) and nausea (31.3%), were frequently treated for potential infection (26.5%), and were admitted (57.2%; 25.0% for, This multicenter cohort study identifies the clinical characteristics and needs of adults with active cancer who present to emergency departments (EDs)., Importance Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

IntroductionEndotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI.Hypothesis/ProblemThe availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance.MethodsThe MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis.ResultsNineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts.ConclusionsThe MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers.BischofJJ, PanchalAR, FinneganGI, TerndrupTE. Creation and validation of a novel mobile simulation laboratory for high fidelity, prehospital, difficult airway simulation. Prehosp Disaster Med. 2016;31(5):465–470.

Author(s): Le Parc, Joanna M.; Bischof, Jason J.; King, Andrew M.; Greenberger, Sarah; Way, David P.; Panchal, Ashish R.; Finnegan, Geoffrey I.; Terndrup, Thomas E. | Abstract: Introduction: Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees’ performance on ETI delivered from both the seated and standing positions.Methods: EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests.Results: Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training.Conclusion: The position of the in-hospital provider, whether seated or standing, had no effect on the provider’s ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.

Emergency medicine residency programs offer Emergency Medical Services (EMS) curricula to address Accreditation Council for Graduate Medical Education (ACGME) milestones. While some programs offer advanced clinical tracks in EMS, no standard curriculum exists. We sought to establish a well-defined EMS curriculum to allow interested residents to develop advanced clinical skills and scholarship within this subspecialty. Core EMS fellowship trained faculty were recruited to help develop the curriculum. Building on ACGME graduation requirements and milestones, important elements of EMS fellowship training were incorporated into the curriculum to develop the final document. The final curriculum focuses on scholarly activities relating to the four core areas of EMS identified by The American Board of Emergency Medicine and serves as an intermediary between ACGME graduation requirements for education in EMS and fellowship level training. Standardization of the EMS scholarly track can provide residents with the potential to obtain competency beyond ACGME requirements and prepare them for success in fellowship training and/or leadership within EMS on graduation.