- Email: [email protected]
210EMF Changes in Health-Related Quality of Life for Geriatric Patients After an Emergency Department Visit
Research Forum Abstracts with severe pain (p ¼ .01). Sex was not associated with receiving an opioid analgesic in the ED, but opioid medication had an inverted U shape association with age (p ¼ .01). After controlling for pain severity in a logistic regression, age was no longer associated with opioid medication. Age, sex, and severe pain were not related to the use of an anesthetic in the ED. There were no time trends in the use of analgesics, opioids, or anesthetics in the ED. 64% were prescribed an analgesic on discharge from the ED including NSAIDS (20%), opioids (54%), acetaminophen (5%), and/or a topical anesthetic (0.7%). Sex was not associated with analgesic or opioid prescription. Age showed an inverted U shape pattern with both analgesic prescription and opioid prescription (both p < .001). Severe pain was associated with both prescribing any analgesia (72% vs 47%, p <.001) and opioid prescribing (36% vs 64%, p < .001). In a multivariate model both age (OR 2.98 and 2.46 for ages 10-64) and severe pain (OR 2.34 and 2.49 for severe pain) were associated with any prescribed and with opioid prescribed analgesia respectively. There were no time trends in prescribing analgesics, opioids, or anesthetics in the ED. Conclusions: Almost 2% of ED patients have a dental complaint and most have severe pain. Less than half were administered an analgesic and about a third received an opioid. Few patients received local anesthetics. Efforts to improve pain control in ED patients with dental pain are recommended.
208
Low-Dose Intravenous Ketamine for Acute Migraine in the Emergency Department: A Randomized Placebo-Controlled Trial
Etchison A, Manfredi L, Mohammed M, Phan V, McAllister KB, Ray M, Heitz C/Carilion Roanoke Memorial Hospital, Roanoke, VA; Carilion Roanoke Memorial Hospital, Roaoke, VA; University of Memphis, Memphis, TN; Lewis-Gale Medical Center, Roanoke, VA
Study Objective: To evaluate and compare analgesic efficacy and safety of low-dose ketamine to saline placebo for treatment of acute migraine in the emergency department (ED). Methods: This prospective, randomized, double-blinded, placebo-controlled trial evaluated patients aged 18 to 65 in the ED with acute migraine. Patients were randomized to receive 0.2 mg/kg ketamine or an equivalent volume of normal saline intravenously. Subjects were assessed at baseline and at 30 and 60 minutes post-treatment for pain Numeric Rating Scale (NRS) scores, categorical pain, functional disability, side effects, and adverse events. The primary outcome was reduction in NRS score at 30 minutes. Secondary outcomes included categorical pain and functional disability improvement, rescue medication request, patient satisfaction, and adverse events. Side effects were evaluated using the Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) model. Results: 35 subjects were enrolled (ketamine¼17, placebo¼18). Subjects averaged 35 years old (SD¼12), were 66% Caucasian and 77% female. There were no statistically significant differences in demographics except age (ketamine¼39 vs placebo¼31, p¼0.032). There was no statistically significant difference in NRS score reduction between arms. Median NRS score reductions at 30 minutes for ketamine and placebo arms were 1 [interquartile range (IQR: 0,3.00)] and 2 (IQR: 0,3.75) (p¼0.590), respectively. Categorical pain and functional disability each improved at 30 minutes in 6 (35%) ketamine subjects, while 9 (50%) placebo subjects improved in categorical pain and 7 (39%) in functional disability. Rescue medication was requested at 30 minutes with similar frequencies in ketamine and placebo arms (71% vs 78%, p¼0.820). Treatment satisfaction was similar in both arms (69% vs 65%, p¼0.909). Ketamine subjects had significantly higher SERSDA scores at 30 and 60 minutes for generalized discomfort with median scores of 4 [(IQR: 2,4) vs 2 (IQR: 0,3) in placebo arm, p¼0.032] and 3 [(IQR: 2,4) vs 1 [(IQR: 0,2) in placebo arm, p¼0.007], respectively. Ketamine subjects had significantly higher SERSDA scores for fatigue at 60 minutes with a median score of 2 [(IQR: 1,4) vs 0.5 (IQR: 0,1.75) in placebo arm, p¼0.040]. All other differences in SERDA scores were not statistically significant. No serious adverse events occurred. Conclusions: 0.2 mg/kg IV ketamine did not produce a greater reduction in NRS score compared to placebo for treatment of acute migraine in the ED. Generalized discomfort was significantly greater in the ketamine arm at 30 and 60 minutes, as well as fatigue at 60 minutes. No other side effects were significantly different between treatment arms at 30 and 60 minutes.
209
Cadaveric Study of Serratus Anterior Block
Allred C, Liu Y, Katrikh A, Challyandra L, Stark E/HarborUCLA Medical Center/LA Biomed, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA; UCLA, Los Angeles, CA
Study Objectives: Serratus plane block was first described by Blanco et al in 2013 as a novel regional anesthetic technique that provides analgesia of the lateral region of
S84 Annals of Emergency Medicine
the thorax. Three case reports and one case series described its efficacy to manage pain in patients with rib fractures. We performed a cadaveric study to conduct an anatomical evaluation of the serratus plane block. Methods: Design: We performed ultrasound-guided serratus plane block on unembalmed cadavers, injecting 20 mL of 1% undiluted lidocaine mixed with food dye in the serratus anterior muscle plane at the mid-axillary line at the level of rib 4. This was followed by tracheal intubation and bag valve mask ventilation at 14 breaths per minute for five minutes. Subsequently, the cadavers were dissected to evaluate the injectate spread in the superficial and deep serratus anterior muscle plane, as well as penetration into intercostal muscles. Maximum spread in the anterior-posterior plane and superior-inferior plane were photographed and measured. Dye staining on relevant nerves was also noted. Setting: Anatomy Laboratory at the Center for Health Sciences - UCLA David Geffen School of Medicine University of California Los Angeles, California, USA. Participants: Unembealmed cadavers with hemithoraces free of prosection or skin and/or chest wall disruption. Results: We designed to inject 5 hemithoraces with the described method above. Data collection is on-going, and expected to be by August. To date, ultrasound-guided serratus plane blocks were performed on 4 hemithoraces in 3 unembalmed cadavers. The average anterior-posterior (AP) spread of injectate was 9.5 cm (Max 12, Min 6 cm). The average superior-inferior (SI) spread of injectate was 15 cm (Max 21, Min 8 cm). The ribs were stained from superior to 2nd rib to the 9th rib in 25%, n ¼ 1 hemithoraces. The long thoracic nerve was stained in 100%, n¼ 4 hemithoraces. Conclusions: There is one previous anatomic evaluation for serratus plane block by Mayes et al. In lightly fixed cadavers where they injected methylene blue into 6 hemithoraces, they showed an average AP spread of 10.4 cm, and an average SI spread of 13.6 cm. Our study is unique in the following ways: 1. we used unembalmed cadavers. Embalmment may change tissue properties and affect injectate spread. 2. Our injectate consisted of 1% undiluted lidocaine with food dye (not methylene blue or latex) to simulate actual clinical use with minimal differences in viscosity of injectate. 3. We ventilated our cadavers post block to resemble a real clinical intervention. Chest wall and thoracic muscle movements likely promote anesthetic spread in living patients and served a role in the efficacy of the regional block. Our results provided an anatomical basis to support the use of serratus anterior block in rib fractures.
EMF
210
Changes in Health-Related Quality of Life for Geriatric Patients After an Emergency Department Visit
Dresden SM, Lindquist LA, Courtney DM/Northwestern University Feinberg School of Medicine, Chicago, IL
Study Objectives: The Geriatric Emergency Department Innovations (GEDI) program has decreased hospitalizations. The impact on health-related quality of life (HRQoL) are unknown. The objective of this study is to evaluate the impact of GEDI on overall self-reported health and priority domains of HRQoL including physical function, anxiety, depression, and the ability to participate in social roles and activities. Methods: We performed a prospective cohort study comparing GEDI patients to control patients. All patients age 65+ were eligible. Patients were excluded if they were non-English speaking, or if they had altered mental status as measured by the six-item screener. Eligible patients provided informed consent while in the ED. Patients were enrolled from 3/2015-8/2015 and from 1/2017 to present. Enrolled patients completed a series of patient reported outcomes measures in the ED using Patient Reported Outcomes Measures Information System (PROMIS). Clinical data were obtained through the Enterprise Data Warehouse. Follow-up measures were performed at 10 days, 4 weeks, and 8 weeks. Follow-up was performed via phone or email per patient’s choice. In this preliminary report, we analyze data from the baseline instruments and 10-day follow-up. Data were recorded in REDCap. Categorical variables were evaluated using chi squared test. Continuous variables were evaluated using Student’s t test. Results: Of the 415 patients approached, 219 provided consent, and 210 completed the baseline measures. There were significant differences between the GEDI and the control groups in age, race, baseline physical function, and baseline depression (Table 1). Compared to national population data across age groups, baseline PROMIS measures indicated that patients in the GEDI group were at the 36th percentile in physical function, 41st percentile for satisfaction with social roles, 53rd percentile for
Volume 70, no. 4s : October 2017
Research Forum Abstracts anxiety, and 53rd percentile for depression. Patients in the control group were at the 40th percentile for physical function, 42nd percentile for satisfaction with social roles, 51st percentile for anxiety, and 49th percentile for depression. At 10 days’ post ED visit, compared to control patients, GEDI patients were less likely to say their overall health was much worse (5.1% vs 23.9%), and more likely to report it as unchanged (35.9% vs 18.2%) (p¼0.03). Compared to control patients there was no significant difference in change of any PROMIS measures at 10 days post ED visit: physical function -2.7 points for GEDI -1.1 points for controls (p¼0.28), satisfaction with social roles -3.0 points for GEDI -1.4 points for controls (p¼0.43), anxiety -2.1 for GEDI -0.8 for controls (p¼0.29), depression -0.6 points for GEDI +0.4 points for controls (p¼0.34). Conclusions: In this preliminary analysis, we have found that geriatric patients in the ED have lower HRQoL related to physical function and social roles than the general population, but nearly average HRQoL for anxiety and depression. At 10 days post ED visit compared to control patients GEDI patients are less likely to report their health as much worse and more likely to report it as unchanged from baseline taken in the ED. However, significant differences between changes in PROMIS measures were not yet observed.
compare patients who did and did not return to the ED within 3 days on demographic characteristics, payer, comorbidity, injury presentation, and substance abuse and mental health diagnoses. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported. Results: A total 2.4 million ED visits among geriatric patients were identified in the study period, of which 49,821 patients met inclusion and exclusion criteria resulting in 55,813 index ED visits with a UTI. A total of 4,862 (9.8%) returned to the ED within 3 days. Of all 3-day return visits, 35% were admitted. 14.4% of return ED visits were to a different facility. The top 3 primary diagnoses at return visits were for UTI (26.6%), septicemia (10.4%), and genitourinary symptoms (7.6%). Among patients with a return ED visit, 2529 (48.2%) were identified as having at least 1 comorbid condition, 934 (17.8%) had a mental health-related diagnosis, and 203 (3.9%) had a substance abuse-related diagnosis. The predictor with the highest independent association with 3-day return ED visits in logistic regression analysis was female sex (OR¼0.63, 95% CI¼0.59-0.67). No other significant independent associations were noted. Conclusions: In this study of 325 non-military licensed EDs in California, 10% of all geriatric patients who were discharged from an ED for UTI returned to the ED within 3-days, and approximately one-third of these return ED visits resulted in admission. Novel approaches, such as acute home health care services, may reduce some of these ED revisits and admissions.
212
The Prevalence of Benzodiazepine Use in a Geriatric Emergency Department Population
Minns AB, Kreshak AA, Tolia VT, Killeen JP/University of California, San Diego, San Diego, CA
211
Emergency Department Revisits Within Three Days of an Emergency Department Discharge for Urinary Tract Infection Among Geriatric Patients
Brennan JJ, Chan TC, Vilke GM, Killeen JP, Hsia RY, Castillo EM/University of California, San Diego, San Diego, CA; Unviersity of California, San Francisco, San Fancisco, CA
Study Objectives: Emergency department (ED) visits for urinary tract infections (UTI) are common among the elderly. Elderly patients have higher rates of complications and treatment failures from UTIs. The purpose of this study was to identify and describe repeat visits to the ED within 3 days following an ED visit with a discharge diagnosis of UTI among geriatric patients. Methods: This was a multi-center retrospective longitudinal cohort study of 325 licensed non-military acute care hospitals in California in 2014 using non-public data. Visits without a valid patient identifier and patients under the age of 65 years were excluded. The primary outcome was 3-day ED utilization following an ED discharge for UTI. Discharge dispositions of expired, discontinued care, and admitted/transferred were excluded as index ED visits. Multivariate logistic regression analysis was used to
Volume 70, no. 4s : October 2017
Study Objectives: The American Geriatric Society (AGS) has placed both benzodiazepines and non-benzodiazepine GABAA receptor (NGBR) agonists on the Beers list of medications to avoid in patient over 65 years old because of the increased risk of confusion, falls/fractures, and overall mortality. Although traditionally used for ambulatory care settings, emergency departments (ED) are starting to use the Beers criteria as a guide for ED prescribing. Despite existing recommendations, these medications are still administered in this vulnerable age group. The purpose of this study was to evaluate emergency department (ED) patients age 65 years old or older who received a benzodiazepine or NGBR during their ED stay. Methods: This was a retrospective observational study conducted at a tertiary care ED from July 1, 2012 to June 30, 2016. Charts from all patients age 65 years old or older were analyzed. We sought to determine the prevalence and pattern of benzodiazepine and NGBR agonist administration while admitted to an emergency department. Descriptive statistics are reported for patients who received these medications. Results: There were 28,356 patients over the age of 65 years old presenting to our ED from July 1, 2012 to June 30, 2016. A total of 1750 (6.2%) patients received a benzodiazepine or NBGR agonist during their ED stay. Of these patients, 784 were males (45%) and 966 were females (55%). Most patients (n¼989, 57%) were between 65 years old and 74 years old, followed by 541 (31%) between 75-84 years old. 220 (13%) patients were 85 years old or older. The most frequently administered medication was lorazepam (n¼820, 47%), followed by diazepam (n¼534, 31%). Zolpidem was given to 265 patients (15%). Chlordiazepoxide was the least frequently administered (n¼17). 101 (6%) patients received more than one type of benzodiazepine. The five most common chief complaints in which benzodiazepines or NBGR agonists were used were shortness of breath (n¼176, 10%) neck/back pain (n¼175, 10%), dizziness/vertigo (n¼129, 7%), abdominal pain (n¼125, 7%), and chest pain (n¼100, 6%). A minority of patients who received these medications presented with a psychiatric chief complaint (24 patients with suicidal ideations; 17 patients with anxiety). Only 10 patients received benzodiazepines for an alcohol-related problem; and 21 patients received benzodiazepines for seizures. 60 patients obtained a psychiatric evaluation during their ED stay. 1026 (58%) patients were admitted to the hospital or transferred to another acute care hospital. 712 (41%) patients were discharged, and 12 patients left against medical advice. Conclusions: Although several major psychiatric and geriatric organizations advise against the use of benzodiazepines and NBGR agonists in patient older than 65 years old, these medications continue to be used for a variety of conditions. Optimizing medication use to treat conditions in the ED while avoiding adverse drug events is often challenging, particularly in the older adult who is already at risk for drug-related problems. Although benzodiazepine administration may at
Annals of Emergency Medicine S85
208
Low-Dose Intravenous Ketamine for Acute Migraine in the Emergency Department: A Randomized Placebo-Controlled Trial
Etchison A, Manfredi L, Mohammed M, Phan V, McAllister KB, Ray M, Heitz C/Carilion Roanoke Memorial Hospital, Roanoke, VA; Carilion Roanoke Memorial Hospital, Roaoke, VA; University of Memphis, Memphis, TN; Lewis-Gale Medical Center, Roanoke, VA
Study Objective: To evaluate and compare analgesic efficacy and safety of low-dose ketamine to saline placebo for treatment of acute migraine in the emergency department (ED). Methods: This prospective, randomized, double-blinded, placebo-controlled trial evaluated patients aged 18 to 65 in the ED with acute migraine. Patients were randomized to receive 0.2 mg/kg ketamine or an equivalent volume of normal saline intravenously. Subjects were assessed at baseline and at 30 and 60 minutes post-treatment for pain Numeric Rating Scale (NRS) scores, categorical pain, functional disability, side effects, and adverse events. The primary outcome was reduction in NRS score at 30 minutes. Secondary outcomes included categorical pain and functional disability improvement, rescue medication request, patient satisfaction, and adverse events. Side effects were evaluated using the Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) model. Results: 35 subjects were enrolled (ketamine¼17, placebo¼18). Subjects averaged 35 years old (SD¼12), were 66% Caucasian and 77% female. There were no statistically significant differences in demographics except age (ketamine¼39 vs placebo¼31, p¼0.032). There was no statistically significant difference in NRS score reduction between arms. Median NRS score reductions at 30 minutes for ketamine and placebo arms were 1 [interquartile range (IQR: 0,3.00)] and 2 (IQR: 0,3.75) (p¼0.590), respectively. Categorical pain and functional disability each improved at 30 minutes in 6 (35%) ketamine subjects, while 9 (50%) placebo subjects improved in categorical pain and 7 (39%) in functional disability. Rescue medication was requested at 30 minutes with similar frequencies in ketamine and placebo arms (71% vs 78%, p¼0.820). Treatment satisfaction was similar in both arms (69% vs 65%, p¼0.909). Ketamine subjects had significantly higher SERSDA scores at 30 and 60 minutes for generalized discomfort with median scores of 4 [(IQR: 2,4) vs 2 (IQR: 0,3) in placebo arm, p¼0.032] and 3 [(IQR: 2,4) vs 1 [(IQR: 0,2) in placebo arm, p¼0.007], respectively. Ketamine subjects had significantly higher SERSDA scores for fatigue at 60 minutes with a median score of 2 [(IQR: 1,4) vs 0.5 (IQR: 0,1.75) in placebo arm, p¼0.040]. All other differences in SERDA scores were not statistically significant. No serious adverse events occurred. Conclusions: 0.2 mg/kg IV ketamine did not produce a greater reduction in NRS score compared to placebo for treatment of acute migraine in the ED. Generalized discomfort was significantly greater in the ketamine arm at 30 and 60 minutes, as well as fatigue at 60 minutes. No other side effects were significantly different between treatment arms at 30 and 60 minutes.
209
Cadaveric Study of Serratus Anterior Block
Allred C, Liu Y, Katrikh A, Challyandra L, Stark E/HarborUCLA Medical Center/LA Biomed, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA; UCLA, Los Angeles, CA
Study Objectives: Serratus plane block was first described by Blanco et al in 2013 as a novel regional anesthetic technique that provides analgesia of the lateral region of
S84 Annals of Emergency Medicine
the thorax. Three case reports and one case series described its efficacy to manage pain in patients with rib fractures. We performed a cadaveric study to conduct an anatomical evaluation of the serratus plane block. Methods: Design: We performed ultrasound-guided serratus plane block on unembalmed cadavers, injecting 20 mL of 1% undiluted lidocaine mixed with food dye in the serratus anterior muscle plane at the mid-axillary line at the level of rib 4. This was followed by tracheal intubation and bag valve mask ventilation at 14 breaths per minute for five minutes. Subsequently, the cadavers were dissected to evaluate the injectate spread in the superficial and deep serratus anterior muscle plane, as well as penetration into intercostal muscles. Maximum spread in the anterior-posterior plane and superior-inferior plane were photographed and measured. Dye staining on relevant nerves was also noted. Setting: Anatomy Laboratory at the Center for Health Sciences - UCLA David Geffen School of Medicine University of California Los Angeles, California, USA. Participants: Unembealmed cadavers with hemithoraces free of prosection or skin and/or chest wall disruption. Results: We designed to inject 5 hemithoraces with the described method above. Data collection is on-going, and expected to be by August. To date, ultrasound-guided serratus plane blocks were performed on 4 hemithoraces in 3 unembalmed cadavers. The average anterior-posterior (AP) spread of injectate was 9.5 cm (Max 12, Min 6 cm). The average superior-inferior (SI) spread of injectate was 15 cm (Max 21, Min 8 cm). The ribs were stained from superior to 2nd rib to the 9th rib in 25%, n ¼ 1 hemithoraces. The long thoracic nerve was stained in 100%, n¼ 4 hemithoraces. Conclusions: There is one previous anatomic evaluation for serratus plane block by Mayes et al. In lightly fixed cadavers where they injected methylene blue into 6 hemithoraces, they showed an average AP spread of 10.4 cm, and an average SI spread of 13.6 cm. Our study is unique in the following ways: 1. we used unembalmed cadavers. Embalmment may change tissue properties and affect injectate spread. 2. Our injectate consisted of 1% undiluted lidocaine with food dye (not methylene blue or latex) to simulate actual clinical use with minimal differences in viscosity of injectate. 3. We ventilated our cadavers post block to resemble a real clinical intervention. Chest wall and thoracic muscle movements likely promote anesthetic spread in living patients and served a role in the efficacy of the regional block. Our results provided an anatomical basis to support the use of serratus anterior block in rib fractures.
EMF
210
Changes in Health-Related Quality of Life for Geriatric Patients After an Emergency Department Visit
Dresden SM, Lindquist LA, Courtney DM/Northwestern University Feinberg School of Medicine, Chicago, IL
Study Objectives: The Geriatric Emergency Department Innovations (GEDI) program has decreased hospitalizations. The impact on health-related quality of life (HRQoL) are unknown. The objective of this study is to evaluate the impact of GEDI on overall self-reported health and priority domains of HRQoL including physical function, anxiety, depression, and the ability to participate in social roles and activities. Methods: We performed a prospective cohort study comparing GEDI patients to control patients. All patients age 65+ were eligible. Patients were excluded if they were non-English speaking, or if they had altered mental status as measured by the six-item screener. Eligible patients provided informed consent while in the ED. Patients were enrolled from 3/2015-8/2015 and from 1/2017 to present. Enrolled patients completed a series of patient reported outcomes measures in the ED using Patient Reported Outcomes Measures Information System (PROMIS). Clinical data were obtained through the Enterprise Data Warehouse. Follow-up measures were performed at 10 days, 4 weeks, and 8 weeks. Follow-up was performed via phone or email per patient’s choice. In this preliminary report, we analyze data from the baseline instruments and 10-day follow-up. Data were recorded in REDCap. Categorical variables were evaluated using chi squared test. Continuous variables were evaluated using Student’s t test. Results: Of the 415 patients approached, 219 provided consent, and 210 completed the baseline measures. There were significant differences between the GEDI and the control groups in age, race, baseline physical function, and baseline depression (Table 1). Compared to national population data across age groups, baseline PROMIS measures indicated that patients in the GEDI group were at the 36th percentile in physical function, 41st percentile for satisfaction with social roles, 53rd percentile for
Volume 70, no. 4s : October 2017
Research Forum Abstracts anxiety, and 53rd percentile for depression. Patients in the control group were at the 40th percentile for physical function, 42nd percentile for satisfaction with social roles, 51st percentile for anxiety, and 49th percentile for depression. At 10 days’ post ED visit, compared to control patients, GEDI patients were less likely to say their overall health was much worse (5.1% vs 23.9%), and more likely to report it as unchanged (35.9% vs 18.2%) (p¼0.03). Compared to control patients there was no significant difference in change of any PROMIS measures at 10 days post ED visit: physical function -2.7 points for GEDI -1.1 points for controls (p¼0.28), satisfaction with social roles -3.0 points for GEDI -1.4 points for controls (p¼0.43), anxiety -2.1 for GEDI -0.8 for controls (p¼0.29), depression -0.6 points for GEDI +0.4 points for controls (p¼0.34). Conclusions: In this preliminary analysis, we have found that geriatric patients in the ED have lower HRQoL related to physical function and social roles than the general population, but nearly average HRQoL for anxiety and depression. At 10 days post ED visit compared to control patients GEDI patients are less likely to report their health as much worse and more likely to report it as unchanged from baseline taken in the ED. However, significant differences between changes in PROMIS measures were not yet observed.
compare patients who did and did not return to the ED within 3 days on demographic characteristics, payer, comorbidity, injury presentation, and substance abuse and mental health diagnoses. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported. Results: A total 2.4 million ED visits among geriatric patients were identified in the study period, of which 49,821 patients met inclusion and exclusion criteria resulting in 55,813 index ED visits with a UTI. A total of 4,862 (9.8%) returned to the ED within 3 days. Of all 3-day return visits, 35% were admitted. 14.4% of return ED visits were to a different facility. The top 3 primary diagnoses at return visits were for UTI (26.6%), septicemia (10.4%), and genitourinary symptoms (7.6%). Among patients with a return ED visit, 2529 (48.2%) were identified as having at least 1 comorbid condition, 934 (17.8%) had a mental health-related diagnosis, and 203 (3.9%) had a substance abuse-related diagnosis. The predictor with the highest independent association with 3-day return ED visits in logistic regression analysis was female sex (OR¼0.63, 95% CI¼0.59-0.67). No other significant independent associations were noted. Conclusions: In this study of 325 non-military licensed EDs in California, 10% of all geriatric patients who were discharged from an ED for UTI returned to the ED within 3-days, and approximately one-third of these return ED visits resulted in admission. Novel approaches, such as acute home health care services, may reduce some of these ED revisits and admissions.
212
The Prevalence of Benzodiazepine Use in a Geriatric Emergency Department Population
Minns AB, Kreshak AA, Tolia VT, Killeen JP/University of California, San Diego, San Diego, CA
211
Emergency Department Revisits Within Three Days of an Emergency Department Discharge for Urinary Tract Infection Among Geriatric Patients
Brennan JJ, Chan TC, Vilke GM, Killeen JP, Hsia RY, Castillo EM/University of California, San Diego, San Diego, CA; Unviersity of California, San Francisco, San Fancisco, CA
Study Objectives: Emergency department (ED) visits for urinary tract infections (UTI) are common among the elderly. Elderly patients have higher rates of complications and treatment failures from UTIs. The purpose of this study was to identify and describe repeat visits to the ED within 3 days following an ED visit with a discharge diagnosis of UTI among geriatric patients. Methods: This was a multi-center retrospective longitudinal cohort study of 325 licensed non-military acute care hospitals in California in 2014 using non-public data. Visits without a valid patient identifier and patients under the age of 65 years were excluded. The primary outcome was 3-day ED utilization following an ED discharge for UTI. Discharge dispositions of expired, discontinued care, and admitted/transferred were excluded as index ED visits. Multivariate logistic regression analysis was used to
Volume 70, no. 4s : October 2017
Study Objectives: The American Geriatric Society (AGS) has placed both benzodiazepines and non-benzodiazepine GABAA receptor (NGBR) agonists on the Beers list of medications to avoid in patient over 65 years old because of the increased risk of confusion, falls/fractures, and overall mortality. Although traditionally used for ambulatory care settings, emergency departments (ED) are starting to use the Beers criteria as a guide for ED prescribing. Despite existing recommendations, these medications are still administered in this vulnerable age group. The purpose of this study was to evaluate emergency department (ED) patients age 65 years old or older who received a benzodiazepine or NGBR during their ED stay. Methods: This was a retrospective observational study conducted at a tertiary care ED from July 1, 2012 to June 30, 2016. Charts from all patients age 65 years old or older were analyzed. We sought to determine the prevalence and pattern of benzodiazepine and NGBR agonist administration while admitted to an emergency department. Descriptive statistics are reported for patients who received these medications. Results: There were 28,356 patients over the age of 65 years old presenting to our ED from July 1, 2012 to June 30, 2016. A total of 1750 (6.2%) patients received a benzodiazepine or NBGR agonist during their ED stay. Of these patients, 784 were males (45%) and 966 were females (55%). Most patients (n¼989, 57%) were between 65 years old and 74 years old, followed by 541 (31%) between 75-84 years old. 220 (13%) patients were 85 years old or older. The most frequently administered medication was lorazepam (n¼820, 47%), followed by diazepam (n¼534, 31%). Zolpidem was given to 265 patients (15%). Chlordiazepoxide was the least frequently administered (n¼17). 101 (6%) patients received more than one type of benzodiazepine. The five most common chief complaints in which benzodiazepines or NBGR agonists were used were shortness of breath (n¼176, 10%) neck/back pain (n¼175, 10%), dizziness/vertigo (n¼129, 7%), abdominal pain (n¼125, 7%), and chest pain (n¼100, 6%). A minority of patients who received these medications presented with a psychiatric chief complaint (24 patients with suicidal ideations; 17 patients with anxiety). Only 10 patients received benzodiazepines for an alcohol-related problem; and 21 patients received benzodiazepines for seizures. 60 patients obtained a psychiatric evaluation during their ED stay. 1026 (58%) patients were admitted to the hospital or transferred to another acute care hospital. 712 (41%) patients were discharged, and 12 patients left against medical advice. Conclusions: Although several major psychiatric and geriatric organizations advise against the use of benzodiazepines and NBGR agonists in patient older than 65 years old, these medications continue to be used for a variety of conditions. Optimizing medication use to treat conditions in the ED while avoiding adverse drug events is often challenging, particularly in the older adult who is already at risk for drug-related problems. Although benzodiazepine administration may at
Annals of Emergency Medicine S85